Midwives are funded to provide care to all residents of their catchment area, regardless of whether or not they have OHIP. A "resident" is a person who maintains an address in the catchment area and includes their baby(ies).
Midwifery services are covered for uninsured clients, and there is funding for consultations and labs, but there are a number of other expenses that uninsured clients may face. Midwives may give clients this handout which explains what services are covered while clients are in midwifery care, and what they will still have to pay out of pocket for (e.g. hospital stays).
Access Without Fear
Many people who are new immigrants or who have precarious immigration status live in fear about their status in Canada. If these clients fear that their health care provider will share information with immigration officials, they are unlikely to seek appropriate health care at for fear of detention and deportation.
In order to provide appropriate care and help clients make choices about their care, midwives may need to know about a client’s status. Instead of adopting a “don’t ask, don’t tell” approach, midwives may consider an “ask and don’t tell” policy, or “access without fear.” Clients should be reassured that they can access midwifery care without fear. As primary care providers, midwives are not obliged to tell authorities information about a client’s immigration status.
Midwives may want to consider posting a sign in their clinic waiting areas that lets people know they can access midwifery care without fear of being reported to immigration.
A person may not have health insurance for several reasons. For example, they could be undocumented, a landed immigrant/permanent resident in the 3-month waiting period to obtain OHIP, or a failed refugee claimant. There are generally three categories of people that midwives in Ontario may serve who fall into the uninsured category:
- Landed immigrants who are new to the country. These are clients who are here ‘legally’ and have been granted immigration status by the government but who are newly arrived to Ontario, which is one of the few provinces that has a three-month waiting period for anyone with landed immigrant status to receive OHIP.
- Uninsured/undocumented clients. These are people who are here without legal status that would entitle them to health insurance coverage. Often these are people who have remained in Ontario after their tourist/student/work visa has expired or whose refugee claim has been denied. People in this category are also referred to as those without status or with precarious status. Some people who are without status may be eligible to apply for refugee status. Once a person has officially made a refugee claim, they will be given an interim federal health (IFH) card. This qualifies them for free health care while their claim is being processed. To access legal information about refugee claims, see the resources section.
- Obstetrical Tourists/Visitors. This refers to people who are not residents, who have no intention of staying Canada and only come here to have their children and return home.
What About Refugees?
If a midwife has a refugee client, they may be eligible for the Interim Federal Health Program (IFHP). It provides health coverage to the following individuals:
- protected persons (e.g., resettled refugees, successful claimants awaiting provincial/territorial health insurance, people who received positive pre-removal risk assessment);
- refugee claimants;
- rejected refugee claimants; and
- people in exceptional circumstances (e.g., applicants with risk of persecution post-removal).
Clients should always check with health insurance providers (e.g. OHIP, Interim Federal Health Program [IFHP], University Health Insurance Plan [UHIP]) if they are unsure about their eligibility for health insurance coverage. Midwives can support clients by finding out if they are aware of their IFHP eligibility and coverage.
It is important to know that immigration status for those with a visa or in the process of refugee claims may change. In other words, during the course care, a client may go from having legal status in Ontario to losing their status and becoming uninsured/undocumented. Or they may begin care in the three-month waiting period and then be granted an OHIP card. If a person obtains health insurance while in midwifery care, they are no longer eligible for uninsured funding.
If the client is not covered by IFHP and has no insurance, they can access the uninsured midwifery funding.
What are Midwives' Legal Obligations in Determining Residency?
Midwives should only be providing care to eligible residents, which is defined as a person who maintains an address in the catchment area. When a client provides their address as part of their client file, the MPG should ensure this falls within the bounds of their catchment, and if not, seek approval from the TPA (as is the case with any client living outside the catchment area). As health care providers, midwives are obligated to respect the privacy of their clients unless there is a legal obligation or permission to report. There is no legal obligation or permission to report to Citizenship and Immigration Canada. Midwives do have an obligation to report OHIP fraud (e.g. if you believe someone is using a fraudulent OHIP number), but not an obligation to proactively confirm whether or not someone is being fraudulent.
Are There any Risks to Midwives Taking Uninsured Clients into Care?
HIROC provides liability insurance for midwives if clients launch a law suit within Canada. HIROC only provides some coverage for suits launched outside of Canada. For that reason, HIROC recommends that all clients who may relocate to a country outside of Canada sign a Governing Law and Jurisdiction Agreement (GLJA). These forms are designed to assist in establishing Canadian jurisdiction for any potential legal actions that may result from care or treatment provided by health-care organizations or Canadian midwives. Identify clients who might need to sign the GLJA by assessing the likelihood of them returning to a foreign country, particularly the United States. If a client doesn't have OHIP coverage, that should be a prompt to inquire a bit further into the strength of their ties to Canada. When in doubt, sign the GLJA. The forms can be found on the joint statements page of the HIROC website. For more information, please contact the AOM’s risk management department.