October 2017

7.3 Extended Health Benefits

Legislative Authority

Sections 2 and 8 of the Act.
Sections 55, 57.1, 57.2, 58, 58.1 and 59 of Regulation 134/98.

Audit Requirements

Adequate documentation is on file to support decisions and issuance of benefits.

Cases are reviewed monthly with the necessary information documented.

Application of Policy

Extended health benefits are issued to cover health-related costs. If the recipient is eligible for extended health benefits, the recipient must present their Ontario health card to a pharmacist along with their prescription.  The health card allows the pharmacist to verify that the person is eligible for coverage under the Ontario Drug Benefit (ODB) program. Direct payment to the recipient or service provider can be made, as appropriate. The health costs must be verified prior to issuing the benefit (e.g., obtain receipts or written estimate).

Drug cards continue to be issued monthly for eligible recipients whose Ontario Works is being provided by First Nations Ontario Works delivery partners that do not have access to the Social Assistance Management System (SAMS).

Regardless of eligibility for extended health benefits, recipients should inquire into alternative health benefit programs such as the Trillium Drug Program, the Ministry of Health and Long-Term Care's Special Drugs Program and Health and Welfare Canada.

Recipients of extended health benefits are not eligible for:

  • mandatory benefits including: guide dog, full-time employment benefit, other employment and employment assistance activities benefit, advance child care; or
  • discretionary benefits except for: health-related discretionary benefits that are issued under the Extended Employment Health Benefit (EEHB) (only during the first six months of employment).

Persons in receipt of extended health benefits have their participation requirements deferred.

Eligibility

Extended Health Benefit (EHB) for Recipients who Cease to be Eligible for Income Assistance

The EHB is provided to recipients who have high prescription drug or other health-related costs but are no longer eligible for income assistance due to income from employment, business income, or other income sources (e.g., Canada Pension Plan, Old Age Security, Employment Insurance, etc.). Recipients are required to continue to meet the prescribed asset limits to be eligible.

In addition, a recipient must have been in receipt of income assistance in the month immediately before the month in which they became eligible for this benefit.

Eligible recipients will receive the EHB as long as their health costs remain higher than the difference between their earned income and the amount of income assistance they were receiving. For example, a single person has monthly budgetary requirements of $721. Their chargeable income is calculated at $730. Their eligible health costs total $250 per month. Their budgetary requirements and health benefits equal $956 per month which exceeds their available income of $971, so the person will continue to receive the EHB.

Recipients who qualify for the EHB may receive the following health benefits if the Administrator is satisfied that they meet eligibility criteria (see Directive 7.2: Health Benefits for more information):

  • prescription drug coverage
  • vision care for dependent children
  • dental care for children aged 17 years and under whose families are residing in a First Nations community (including children in temporary care)*
  • diabetic supplies, surgical supplies and dressings
  • medical transportation costs over $15 per month per benefit unit
  • consumer contribution for an assistive device and eligibility assessment under the Assistive Devices Program (ADP)
  • batteries and necessary repairs for mobility devices
  • routine eye examinations once in every 24-month period

*Note: Effective January 1, 2016 dental benefits for dependent children agwed 17 and under whose Ontario Works is being delivered by a Consolidated Municipal Service Manager or District Social Services Administration Board will be provided by the Ministry of Health and Long-Term Care through the Healthy Smiles Ontario Program. Dependent children whose Ontario Works is being provided by a First Nations Ontario Works delivery agent will continue to have access to mandatory dental benefits under Ontario Works until December 31, 2017.

While in receipt of the EHB, the recipient is required to report any changes in their circumstances to support ongoing eligibility assessment. Cases should be reviewed monthly.

Extended Employment Health Benefit (EEHB)

A person who was in receipt of income assistance and, due to starting employment or having increased earnings, is no longer eligible for income assistance, is eligible for the EEHB if:

  • they meet all other conditions of eligibility for income assistance except the condition that their budgetary requirements exceed their income, their assets are within the allowable limit and participation requirements;
  • they are exiting income assistance due to employment income;
  • they are not eligible for the EHB; and
  • the benefits payable under the EEHB are not recoverable, partially or completely, under a benefit plan available from an employer (e.g., if a recipient is only eligible for dental coverage through their employer plan, they would be eligible for all benefits under the EEHB except for dental coverage).

Recipients do not need to have the following factors assessed to determine eligibility for the EEHB in the first month of ineligibility for financial assistance:

  • eligibility for the EHB; and
  • verification that the employer does not provide comparable coverage of the benefits payable under the EEHB.

A recipient is considered to be in their first month of ineligibility for financial assistance when:

  • they have income in excess of their budgetary requirements for the month in question and that income includes earnings from employment, operating a business or from a training program; and
  • they were eligible for financial assistance in the month prior.

There is no limit on the number of times EEHB can be issued for a one-month period for recipients who periodically temporarily exit Ontario Works due to fluctuations in earnings.

If the client is ineligible for financial assistance for one month only (i.e., the client meets eligibility requirements in the second month), then no further assessment of EHB/EEHB is required.

However, if the client remains, or is expected to remain, ineligible for financial assistance beyond the first month of ineligibility, then the full EHB/EEHB assessment must be conducted.

If the client is subsequently determined not eligible for EHB/EEHB, their eligibility for EEHB in the first month remains unaffected.

A person is eligible for the EEHB on the day they become ineligible for income assistance. A person becomes ineligible for this benefit after six months, on the last day of the sixth month (e.g., if a person is ineligible for income assistance in January 2017, eligibility for the EEHB begins on February 1, 2017 and eligibility ends on July 31, 2017).

If a recipient of EEHB is terminated from employment they may continue to receive this benefit for up to six months if they continue to meet other eligibility criteria.

Recipients who qualify for the EEHB can receive the following mandatory health benefits if the Administrator is satisfied that they meet eligibility criteria (see Directive 7.2: Health Benefits for more information).

  • prescription drug coverage
  • vision care for dependent children
  • dental care for children aged 17 years and under whose families are residing in a First Nation community (including children in temporary care)*
  • diabetic supplies, surgical supplies and dressings
  • medical transportation costs over $15 per month per benefit unit
  • consumer contribution for an assistive device and eligibility assessment under the ADP
  • batteries and necessary repairs for mobility devices
  • routine eye examinations once in every 24-month period

*Note: Effective January 1, 2016 dental benefits for dependent children aged 17 and under whose Ontario Works is being delivered by a Consolidated Municipal Service Manager or District Social Services Administration Board will be provided by the Ministry of Health and Long-Term Care through the Healthy Smiles Ontario Program. Dependent children whose Ontario Works is being provided by a First Nations Ontario Works delivery agent will continue to have access to mandatory dental benefits under Ontario Works until December 31, 2017.

In addition, the Administrator may provide the following health-related discretionary benefits:

  • dental services for adults
  • eye-glasses for adults
  • prosthetic appliances
  • any other special service, item or payment (excluding the cost of prescription drugs) authorized by the Director, if it is related to the health of a member of the benefit unit

When issuing the EEHB, a copy of the recipient's employer benefit plan (if in existence) should be visually verified and documented in the Social Assistance Management System (SAMS). First Nations should visually verify and document the recipient's employer benefit plan in their file system.

Extended Employment Health Benefit - Second Six-Month Period

The EEHB may be provided for an additional six-month period if the Administrator is satisfied that not providing the benefit may:

  • be harmful to the health of a member of the benefit unit; or
  • may jeopardize the employment of a member of the benefit unit; and
  • the benefits are not provided under an employer health plan.

During the second six-month period, recipients are no longer eligible for drug coverage. Help with drug coverage in the second six-month period is limited to assisting with the quarterly deductible costs of the Trillium Drug Program (see below) if the employer does not offer a drug plan.

Recipients continue to be eligible for other health benefits as provided during the first six-month period if not made available under the employer plan.

Trillium Drug Program

The Trillium Drug Program deductible is based on income and family size. Each year starting August 1, an individual/family must pay drug costs up to the appropriate deductible level (approximately 4% of net family income) before they are eligible for drug coverage. The program runs from August 1 of one year to July 31 of the following year.

The deductible can be paid in four installments over the Trillium program year (August 1 to July 31 of the following year). Prorated deductibles are calculated when a family enters the program mid-way through the year. The deductible is approximately 4% of net family income, adjusted by family size. After the deductible is paid, the family will pay $2 for each prescription for the year.

In the second six-month period, recipients of the EEHB are required to provide copies of receipts to confirm expenditures (deductible amounts). The $2 charge for each prescription, once the deductible is paid, is not covered under the EEHB. The amount reimbursed is based on the amount of the quarterly deductible (as determined by Trillium) that falls within the six-month period (e.g., if recipient has a quarterly deductible of $200 and is eligible for the second six month period from February 1, 2017 to July 31, 2017, receipts for that time period will be reimbursed up to $200).

The receipts are visually verified and documented in the Social Assistance Management System (SAMS). First Nations should visually verify and document costs using their file systems.

The original receipts must be returned to the recipient, as they are required for verification of eligibility for Trillium.

Applicants Awaiting ODSP Determination

Extended health benefits may be provided to recipients awaiting ODSP determination:

  • who are not eligible for Ontario Works because their income exceeds budgetary requirements; and
  • who meet all other criteria of eligibility.

Recipients awaiting ODSP determination who are eligible for extended health benefits can only receive prescription drug coverage.

This benefit is provided if the applicant or spouse:

  • is awaiting ODSP determination;
  • has income that is less than the sum of their budgetary requirements and their monthly prescription drug costs;
  • has not previously been refused eligibility for assistance under ODSP or the Family Benefits Act (FBA); and
  • is diagnosed with haemophilia HIV infection, endogenous growth hormone deficiency, cystic fibrosis, thalassemia, anaemia of end-stage renal disease, Gaucher disease, treatment-resistant schizophrenia, or organ or bone marrow transplant, and they have the matching prescribed drug.

Payments Under the 1986-1990 Hepatitis C Settlement Agreement

A recipient who receives payment for loss of income or support under the 1986-1990 Hepatitis C Settlement Agreement, who as a result is ineligible for financial assistance, is eligible for extended health benefits.

Recipients who are eligible for this benefit may receive the following mandatory health benefits if the Administrator is satisfied that they meet eligibility criteria (see Directive 7.2: Health Benefits for more information):

  • prescription drug coverage
  • vision care for dependent children
  • dental care for children aged 17 years and under whose families are residing in a First Nation community (including children in temporary care)
  • diabetic supplies, surgical supplies and dressings
  • medical transportation costs over $15 per month per benefit unit
  • consumer contribution for an assistive device and eligibility assessment under the ADP
  • batteries and necessary repairs for mobility devices
  • routine eye examinations once in every 24-month period

This benefit is provided if:

  • the person's ineligibility for income assistance is the direct result of receiving a payment for loss of income or a loss of support made under the Agreement;
  • the person is otherwise eligible for assistance in the month; and
  • on April 1, 1999, the person was a member of the benefit unit under the Ontario Works Act, 1997; the Ontario Disability Support Program Act, 1997; or the Family Benefits Act.