Uninsured Funding

The Ontario government provides funding to cover the cost of laboratory and consultation fees for uninsured clients who are residents of Ontario. The intention of the funding is to facilitate midwifery care for people living in Ontario, not for people visiting in order to have a baby with the plan of returning to their home country, who may be defined as a medical tourist. Uninsured midwifery clients are eligible for funding to cover pregnancy related third-party services for the full extent of their time in midwifery care (e.g. 8 weeks after the EDD).

Fundable & Non-Fundable Services

Only services that are covered by OHIP and directly relate to or impact the pregnancy are covered by the uninsured funding. The funding is tied to the OHIP Schedule of Benefits, which is available online and pertains to diagnostic tests and physician services/consultations in hospital and in the community. Facility fees, drugs and equipment are not covered by this funding. Services include:

  • Obstetrical referral/consultation/transfer (prenatal, intrapartum, postpartum)
  • Anesthetic referral/consultation
  • Surgical assist
  • Referrals to specialist physicians (e.g endocrinology, hematology, urology, cardiology)
  • Lab work (e.g. routine prenatal blood work, glucose testing, GBS)
  • Prenatal genetic testing (IPS/FTS)
  • Ultrasound

Services that are NOT covered by this funding include:

  • NIPT (Non-Invasive Prenatal Testing)
  • Hospital stays & facility fees

Uninsured clients are still required to pay for hospital stays, which generally range from $500-$3,000 per day. Midwives may try negotiating a reduced rate for hospital fees with your hospital administration. Click here for a customizable template letter to give to the hospital finance office to set up a payment plan for the client. Click here for other points midwives can consider about hospital stays for uninsured clients.

Accessing the Funding

1. During the annual budget process, MPGs notify your TPAs of the anticipated uninsured client numbers based on the previous year.

2. The TPA  then allocates funds per uninsured client in order to cover physician and laboratory/diagnostic services for these clients. 

3. When an uninsured client comes into care, have the client sign the consent form to enable the TPA to access the necessary personal health information required to facilitate the funding. Keep a copy of this in the client’s chart, and send a copy of the signed consent form to the TPA. Since midwives are covered under the Personal Health Information Protection Act, it is good practice to get your clients to sign a consent form that gives permission for their personal health information to be shared with the TPA. Please see the template consent form that has been reviewed by HIROC for this purpose.

4. Upon making a referral to a lab or physician, the client must be given the billing letter to provide to the physician/lab, OR the midwife can send the billing letter to the physician/lab at the time of referral. The billing letter should be given to each physician or lab who provides diagnostic tests, consults, or who accepts a referral or transfer of care.

5. The physician/lab invoices the TPA for the services provided at the rates set in the Schedule of Benefits for the services they provide to uninsured midwifery clients. The TPA will then issue a payment directly to the health physician/lab. Neither clients nor MPGs should be paying out of pocket for services covered by this funding. If the client does pay for the service, she should notify her MPG, and then the MPG should inform the AOM and the TPA so they may inform the Ministry.

If the lab is unfamiliar with this process, you may send them this memo (PDF, 254 KB) from the OMP to labs explaining the funding. If you encounter further issues with the lab, you can ask to speak to the director/owner of the lab and assure them that they will be paid by the Ministry of Health directly. If they are still hesitant, you can direct them to the Manager of the Ontario Midwifery Program

6. The MPG sends a copy of each client’s billing letter to the TPA in order to cross reference invoices sent by physicians/labs. If the billing/referral letter is not provided, invoices cannot be processed by the Transfer Payment Agency.

    Eligibility

    A client is eligible for this funding if:

    • They are eligible for midwifery care
    • They do not have health insurance (e.g. OHIP, IFH, UHIP, or private insurance that provides coverage for pregnancy care)
    There are no financial requirements associated with the eligibility for this funding. If a client meets the eligibility criteria for midwifery care and does not have health insurance, then they are eligible to access this funding. If a client declines the funding and wishes to pay out of pocket, they may do so.

     

    Students

    If a student meets the eligibility criteria for midwifery care and does not have health insurance, then they are eligible for this funding. International students are often required to acquire coverage under the University Health Insurance Plan (UHIP). According to the UHIP website, pregnancy related services by physicians are covered. Clients should check with UHIP to clarify what services are covered under their individual plan.

    Clients from Other Provinces

    Individuals who moved to Ontario from another Canadian province are covered by the province from which they moved during their 3 month OHIP waiting period. Therefore, these clients should not be accessing this funding because they are insured.

    Due to reciprocal billing agreements between all of the provinces except Quebec, health services are typically billed directly to the person’s “home” province so that the health card holder does not need to pay out of pocket at the point of care. In certain cases, including for people with Quebec health cards, clients may be asked to pay up front and seek reimbursement from their provincial insurance plan. However, medically necessary care cannot be denied if the person is unable to pay up front. More information regarding health coverage for people moving between Canadian provinces can be found here.

    If a person moved from another Canadian province to Ontario but did not previously have provincial health insurance coverage (e.g. they were undocumented), then they would be eligible for this funding.

    Clients Who Decline OHIP for Religious Reasons

    Anyone who meets the eligibility criteria for midwifery care who is without health insurance is eligible for this funding. However, if a client is eligible for OHIP but chooses not to have it for religious reasons (such as Old Order Mennonites/Amish), they may also be unwilling to access this funding, which ultimately comes from the government and through mechanisms similar to OHIP funding. Clients are under no obligation to access this funding; they are able to pay out of pocket for services if they wish.