September 2017

9.19 - Transitional Health Benefit

Summary of Legislation

Recipients who leave ODSP for employment can continue to receive coverage for prescription drugs, dental and vision care and batteries and repairs for mobility devices unless or until the employer provides coverage that is comparable to the benefits available under ODSP.

Legislative Authority

Section 11.1 (1) of the Ministry of Community and Social Services Act

Summary of Directive

Recipients and eligible members of the benefit unit can receive the Transitional Health Benefit if the recipient is no longer financially eligible for ODSP income support as a result of employment earnings, paid training or income from self-employment and if comparable benefits are not provided by the employer.

Eligible members of the benefit unit include the recipient, spouse and dependent children. Dependent adults are not eligible for the Transitional Health Benefit.

The Transitional Health Benefit includes:

  • prescription drugs;
  • dental benefits (excluding dependent children);
  • vision care benefits, including routine eye examinations; and
  • batteries and repairs for mobility devices

The Transitional Health Benefit can be provided to eligible ODSP recipients until comparable coverage is available from the employer.

Intent of Policy

To encourage recipients to accept employment and become financially independent by removing barriers to exiting social assistance for employment.

Application of Policy

Eligibility

The Transitional Health Benefit is available to any recipient (and eligible members of the benefit unit) who is a resident of Ontario and who ceases to be eligible for ODSP Income Support due to the following:

  • The income of the recipient, including members of the benefit unit, equals or exceeds their budgetary requirements; and
  • The income of the recipient, including members of the benefit unit, includes earnings from employment or a training program, or net positive income from self-employment; and
  • The employer does not provide health benefit coverage that is comparable to benefit coverage under the Transitional Health Benefit.

Note: In the first month of ineligibility for income support, verification of the employer’s benefit coverage is not required. See section below on “Transitional Health Benefit in the First Month of Ineligibility for Income Support” for further information.

Determining Eligibility

Recipients who become ineligible for ODSP due to income in excess where income includes employment earnings, paid training or net positive income from self employment should be assessed for eligibility for the Extended Health Benefit first.

The Extended Health Benefit is available to ODSP recipients and members of the benefit unit with high health costs to reduce the impact of losing health care benefits as a result of income exceeding the budgetary requirements (see Directive 9.10 Extended Health Benefit for eligibility requirements) Recipients cannot receive both the Extended Health Benefit and the Transitional Health Benefit at the same time.

If a recipient is not eligible for the Extended Health Benefit, staff should assess eligibility for the Transitional Health Benefit by ensuring the recipient's income includes employment earnings, paid training, or net positive income from self-employment and determining whether the employer provides health benefit coverage that is comparable to benefit coverage under the Transitional Health Benefit.

  • In the first month of ineligibility for income support, assessing eligibility for Extended Health Benefit is not necessary, unless the recipient requires benefits only provided under Extended Health Benefit. See section below on “Transitional Health Benefit in the First Month of Ineligibility for Income Support” for further information.

If the employer provides health benefit coverage that is comparable to benefit coverage under the Transitional Health Benefit, the recipient is not eligible for the Transitional Health Benefit (see section below on "Benefits Covered by the Transitional Health Benefit").

Unlike the Extended Health Benefit, there is no requirement that a recipient have health-related costs greater than the amount of income that exceeds their budgetary requirements to be eligible for the Transitional Health Benefit.

Where the recipient meets all eligibility requirements for the Transitional Health Benefit, they can begin to receive the benefit in the month he/she becomes ineligible for Income Support.

Where an employed recipient is not eligible for Transitional Health Benefit (i.e. receiving comparable employer heath benefits) and then moves to employment where comparable employer health benefits are not provided, the recipient may be eligible for the Transitional Health Benefit if they meet all eligibility criteria.

Benefits Covered by the Transitional Health Benefit

Drug Coverage

  • The cost of drugs prescribed by an approved health professional for members of the ODSP benefit unit are covered if the drugs have been approved by the Ministry of Health and Long-Term Care (MOHLTC) and purchased from a dispensary during any month in which the recipient requiring the drugs is a member of the benefit unit. (See Directive 9.8 Drug Benefits)

Dental Coverage

  • The cost of dental services, procedures, and fees outlined in the MCSS Schedule of Dental Services and Fees. (See Directive 9.7 Dental Benefits)
  • Recipients and eligible members of the benefit unit will receive a dental card to access this benefit

Vision Care Benefits

  • A new pair of frames and lenses every 3 years, if requested. (Children may receive replacement lenses and/or frames as needed without restrictions)
  • Routine eye examinations once every 24 months where not covered by OHIP.

Batteries and Repairs for Mobility Devices

  • Coverage for the cost of batteries and necessary repairs for mobility devices if these costs are not otherwise reimbursed. (See Directive 9.13)

Transitional Health Benefit Grant Letter

Once the recipient's eligibility for the Transitional Health Benefit is confirmed, the recipient signs the Transitional Health Benefit Grant Letter. This letter outlines the information and documentation required to receive the Transitional Health Benefit.

The recipient signs the grant letter to acknowledge that they meet the eligibility requirements for the Transitional Health Benefit. The grant letter will be valid for a one-year period, subject to changes in the recipient's circumstances. On an annual basis, staff will reconfirm eligibility and have the recipient sign a new grant letter if the recipient continues to be eligible for the Transitional Health Benefit.

When providing the Transitional Health Benefit, staff should document in SAMS that the recipient's employer benefit plan has been verified. The Transitional Health Benefit Grant Letter must be completed in full, and signed by the recipient and spouse, if applicable. Information concerning the employer benefit plan and all supporting documents should be kept on file. A signed copy of the grant letter is retained on the master file, and a copy provided to the recipient.

As part of the Transitional Health Benefit application process, the Rapid Reinstatement provisions should be outlined by staff to inform the recipient that, if they lose their employment, they can be rapidly reinstated if they qualify financially and meet certain eligibility conditions.

Transitional Health Benefit in the First Month of Ineligibility for Income Support

For the first month of ineligibility for income support, the following policies and procedures related to assessing Transitional Health Benefit are not required:

  • Extended Health Benefit does not need to be assessed prior to approving  Transitional Health Benefit, unless the recipient requires benefits that are only covered under Extended Health Benefit (e.g., Mandatory Special Necessities);
  • Verification that the employer does not provide comparable coverage does not need to be obtained; and
  • The Transitional Health Benefit Grant Letter does not need to be signed by the recipient.

A recipient is considered to be in their first month of ineligibility for income support when:

  • They have income in excess of budgetary requirements for the month in question and that income includes earnings, training or self-employment income; and
  • They were eligible for income support in the month prior.

There is no limit on the number of times Transitional Health Benefit can be issued for a one-month period for recipients who periodically temporarily exit ODSP due to fluctuations in employment income.

If the recipient is ineligible for income support for one month only (i.e., the recipient meets eligibility requirements in the second month), then no further assessment of Extended Health Benefit or Transitional Health Benefit is required.

However, if the recipient remains, or is expected to remain, ineligible for income support beyond the first month of ineligibility, then the full Extended Health Benefit or Transitional Health Benefit assessment must be conducted, per existing policy.

  • If the recipient is subsequently determined not eligible for Extended Health Benefit or Transitional Health Benefit, their eligibility for Transitional Health Benefit in the first month remains unaffected.

Voluntary Withdrawals from the Transitional Health Benefit

A recipient may request to withdraw from receiving the Transitional Health Benefit. If the request is made in writing, the letter shall be attached to the Transitional Health Benefit Grant Letter and filed. If the request is made verbally, staff should advise the recipient to submit a letter regarding the request. If not received, the request to withdraw is documented in SAMS and the benefits are terminated.

Related Directives

1.3 Rapid Reinstatement
9.7 Dental Benefits
9.8 Drug Benefits
9.10 Extended Health Benefit
9.13 Mobility Devices Batteries and Repairs
9.14 Vision Care Benefits