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Prepared by Johnson Inc. Richmond Hill Ontario, September 1999
Several programs are available to provide financial assistance for seniors, social assistance recipients or Ontario residents in financial difficulty at both the provincial and community levels.
Most of these programs are provincial programs tied into or associated with the Ontario Health Insurance Plan (OHIP).
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Drug Programs |
In Ontario, there are three Drug Programs: Ontario Drug Benefit Program, Trillium Drug Program, and Special Drugs Program.
These programs are all administered by the Drug Programs Branch of the Ministry of Health of Ontario. Among other functions, this branch also is responsible for the publication of the Ontario Drug Benefit Formulary/Comparative Drug Index. If a drug prescribed by a doctor is not on this list, it is not eligible for reimbursement, although under special circumstances, exceptions can be made (see ODB Section 8 mechanism). The Formulary is reviewed regularly, with drugs and supplements being added and deleted depending on what the Branch deems necessary.
The Drug Quality and Therapeutics Committee (DQTC) of the Drug Programs Branch evaluates requests for new drugs to be added to the Formulary and makes recommendations. This Committee serves other advisory functions relating to pharmaceutical, pharmacological and health matters.
The Ontario Drug Benefit (ODB) Program covers most of the cost of prescription drugs and life sustaining products listed in the Formulary for Ontario residents who qualify for the Program.
To qualify for ODB coverage, the person must be:
At present, there are approximately 2600 prescription drug products and approximately 170 limited-use drug products listed in the ODB Formulary. The Formulary also includes some nutritional products and diabetic testing products. The drugs may be purchased at any pharmacy in Ontario that is on-line with the ministry’s Health Network, or through an Ontario doctor licensed to sell prescription drugs.
ODB recipients will be asked to pay up to $2 per prescription if they are:
ODB recipients will be asked to pay the first $100 in prescription drug costs each and then up to $6.11 for each prescription after that if they are:
Residents aged 65 or more, need only show their Health Card to show eligibility for Ontario Drug Benefits when filling a prescription.
ODB Section 8 Mechanism
Through the Ontario Drug Benefit (ODB) program, the Ministry of Health covers the costs of prescription drug products for the majority of illnesses and conditions. In rare circumstances, a person may be unable to use any of the drug products covered by the ODB program. In other cases, new drugs approved for sale in Canada but not yet covered by the ODB program may be, based on the prescriber's opinion, the only treatment available to improve a patient's health. In these exceptional circumstances, a request for special coverage of a non-listed drug product not normally covered under the ODB program can be made. This process is known as Section 8.
To request special coverage through Section 8, individuals must already be eligible for drug coverage under the ODB. To apply, the prescribing physician requests coverage for a specific period of time, for a particular drug product not normally covered under the ODB program. As part of the request, the doctor must submit relevant medical information including an indication of why the applicant cannot use other products covered by the program. Medical experts will review the doctor's request and will advise him/her whether coverage has been approved.
Like drug products covered by the ODB program, if an individual’s Section 8 request is approved, he or she will be asked to pay some portion of the drug product cost.
The Trillium Drug Program helps people who have high drug costs in relation to their income. Once an application is approved, the program covers:
Residents can apply to the Trillium Drug Program if they:
The Trillium Drug Program has an annual deductible that is based on income and family size. Each year starting August 1, recipients must pay for drug costs up to their deductible level before they are eligible for drug coverage. Once the deductible is paid, eligible people receive drug coverage until July 31 of the following year. All eligible people may be asked to pay up to $2 per prescription each time they purchase a covered drug product in Ontario.
The program runs from August 1 of one year to July 31 of the following year. The following is a sample of income-based deductible ranges:
Only certain drug costs count towards the Trillium deductible or as program benefits. Recipients are encouraged to check with their pharmacist or the program to make sure prescriptions are:
Inquiries may be directed to the Trillium Program Hotline at 18005755386.
Trillium application kits are available at your local pharmacy or by calling the Ministry of Health at 1-800-268-1154, in Toronto (416) 314-5518.
This program provides benefits for those with a need for a particular drug used in the treatment of specific conditions. These include:
This program does not have any deductibles or co-payments. To be eligible for the Special Drugs Program the individual must meet the following conditions:
The treatment may be limited to certain locations that have been designated to provide these treatments. The attending physician will be able to direct the patient to the closest location.
For more information, you may contact an OHIP office in your area. A list of the OHIP office locations can be found in Appendix 1.
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Assistive Devices Program (ADP) |
This program is available to help people who have a long-term physical disability to get the equipment and supplies that they need for day to day living. There are numerous categories covered under the ADP ranging from wheelchairs to diabetic supplies. The amount of coverage varies by category and ranges from a fixed amount to 75% of the cost to annual grants sent directly to the individual.
ADP covers over 15,000 separate pieces of equipment or supplies. The following is a list of the categories of equipment covered by the ADP:
There are certain conditions to be met in order to be eligible for a particular device or supply. The individual must:
All device costs must be pre-approved by ADP. The process begins with an Equipment and Supply Authorisation form for the required device or supply. There are several sections, each of which will be completed either by the individual applying for the device, the medical specialist or doctor, or the ADP registered vendor. The doctor or medical specialist will have to examine the individual and include a medical diagnosis on the form. The Equipment and Supply Authorisation form can picked up at an ADP registered vendor or by calling:
ADP generally will not pay for equipment or supplies available under the Workplace Safety & Insurance Board (WSIB formerly WCB), or to Group ‘A’ veterans for their pensioned conditions. ADP also does not pay for replacement during the minimum replacement period if the original equipment is lost, stolen, or damaged due to misuse.
For some devices, an individual may be eligible to receive more than the set limit if receiving social assistance benefits under Ontario Works (OW), Ontario Disability Support Program (ODSP) or Assistance to Children with Severe Disabilities (ACSD). This, however, does not guarantee 100% coverage of the cost.
There are other sources of funding that may be able to help the individual in financing his / her share of the cost of the equipment, device, or supply needed such as:
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Home Oxygen Program (HOP) |
HOP pays for oxygen and oxygen delivery equipment, such as concentrators, cylinders, liquid systems and related supplies, such as masks and tubing for any Ontario resident with a valid Health Card and who has a chronic illness or dysfunction that requires long term oxygen therapy.
HOP pays 100% of the cost of oxygen and related equipment for seniors over 65 and those on social assistance. Those on home care or residing in a long-term care facility and all others will be reimbursed at 75%.
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Communication Devices |
The following communication aids are covered by the ADP:
Once the individual, the doctor, and the ADP authoriser have completed the form and the appropriate communication aid has been determined, ADP will then pay 75% of the approved cost to a maximum of:
Those receiving social assistance benefits under Ontario Works, Ontario Disability Support Program, or Assistance to Children with Severe Disabilities may be eligible to receive more money.
ADP will pay 75% of the cost of replacement of an aid up to a maximum amount at the end of a certain time if the aid:
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Diabetic Equipment and Supplies |
Ontario residents of any age who have a valid Health card and use insulin can apply for help in buying glucose monitoring equipment and supplies if they have no other health insurance that covers these items.
If the individual is 65 or older, ADP will provide a grant of $125 once a year. This represents about 75% of the cost of needles and syringes for the average insulin user.
Regardless of age, ADP will pay 65% of the cost of a regular blood glucose meter to a maximum of $75. For the visually impaired, the maximum is $455 for a talking meter. ADP will pay for a new meter once every 5 years.
For supplies used with the glucose meter, such as lancets, penlets and testing strips, ADP pays up to 65% of the cost to a maximum of $500 per year.
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Enteral Feeding Supplies |
ADP covers feeding bags and containers, feeding tubes and accessories, but not feeding formula, for any Ontario resident who has a valid Health card and a chronic disability that requires enteral feeding supplies. ADP does not cover enteral feeding pumps and supplies used in institutions, such as chronic care hospitals and long-term facilities. ADP will cover the cost of an enteral feeding pump for those who are on continuous feeding for 6 or more hours a day.
Once the individual, the doctor, and a registered nurse, dietician, or occupational therapist has completed the form and the appropriate supplies have been determined, ADP will then pay 75% of the approved cost. The ADP registered vendor will bill ADP directly for a portion of the cost and the individual will be responsible for the remainder. ADP will pay for the replacement of an enteral feeding pump at the end of 5 years if the pump is no longer working and cannot be repaired. When more supplies are needed the individual simply presents the green copy of the ADP form to the ADP registered vendor.
Any changes that differ too much from the original list of approved supplies will need to be approved before purchase. Documentation from the individual’s doctor justifying the change will be required. A new application and doctor reassessment is required every 2 years.
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Hearing Devices |
The following hearing aids are eligible for the ADP:
Anyone with a valid health card and a long-term physical disability that requires the use of a hearing aid for six months or more can apply.
An ADP form should be completed by the individual, the doctor, the ADP authoriser, the ADP dispenser and the ADP registered vendor. The individual should also have a hearing test before being fitted for a hearing aid. There may be a charge for this test. The hearing test can be performed either by the ADP-registered authoriser/dispenser after the doctor has completed his section of the form, or by an audiologist who is a registered authoriser with ADP.
Once a dispenser registered with ADP has fitted the hearing aid, the dispenser charges ADP directly for 75% of the cost of the hearing aid, up to a maximum of $500 (or $1,000 if two hearing aids are being purchased). The individual is charged the remaining cost. The registered vendor will charge a dispensing fee that varies depending on the hearing aid bought.
If an FM system is being purchased, ADP will pay 75% up to a maximum of $1,350 of the cost of the ADP listed device and dispensing fee.
The individual has 30 days to try out the hearing aid. The hearing aid can be returned during this period if the individual is not satisfied. The vendor may charge a handling fee.
The hearing aid will have a minimum manufacturer’s warranty of one year. After that, however, the individual is responsible for the cost of any repairs. If the hearing aid or FM system is no longer working and cannot be repaired at a reasonable cost, ADP will help replace it every three years. Should the person’s condition change, ADP will contribute to the cost of a new hearing aid after the doctor explains the need for the change.
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Orthotic Devices |
ADP will cover the cost of custom-made braces and splints and selected paediatric orthoses for any Ontario resident who has a valid Health Card, is physically disabled, and requires a custom-made orthoses for 6 or more months to perform a range of daily activities. Selected paediatric orthoses are made available for those who are physically disabled and 18 or younger.
The following is a list of orthotic devices that ADP does not cover:
The individual, a medical specialist, and afterwards, the ADP approved authoriser (a Canadian board-certified orthotist) will need to complete an ADP form. The rehabilitation assessor will also complete part of the form should the individual require physiotherapy or occupational therapy.
For certain devices such as complex custom-made parapodiums and reciprocating gait orthoses the individual will also be required to make an appointment with an orthotic clinic. ADP has a list of locations of these clinics.
Once the form is complete, the ADP registered vendor will charges 75% of the approved cost of the device directly to ADP and the individual pays the remaining 25%.
ADP will pay 75% of the replacement cost if the individual’s medical condition or size changes. ADP will also pay 75% of the approved cost after one year if the custom-made orthosis moulded on the individual’s body or a paediatric orthosis, or after two year if the custom-made orthoses moulded to a model of the individual’s body, standers, or parapodium no longer meets the individual’s need.
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Ostomy Supplies |
Any Ontario resident with a valid Health Card and who has a permanent colostomy, ileostomy, urostomy, ileal conduit or continent pouch/reservoir can apply for a grant to purchase the necessary supplies. Children who require the use of ostomy supplies for 3 months or longer may also apply. Residents of a chronic care hospital are not eligible for the grant.
An Ostomy Grant Applicant Information from must be completed by both the individual applying for the grant and the doctor. The doctor will certify that the individual has a permanent ostomy.
Once the Ministry of Health receives and approves the application, the individual will receive the grant in two instalments. The first instalment will arrive about six weeks after the application is received, the second will arrive about six months later. The grant is limited to $600 for one ostomy or $1,200 for two ostomies. Residents of Long Term Care facilities are eligible for $800 per ostomy.
Enterostomal therapists working in hospitals or out of local health care agencies can help the individual on deciding on the best product and will also help in how to use it. Generally, the home health care supply outlet or pharmacy may also have staff who can help.
The Ministry of Health may ask to see receipts of the purchase of ostomy supplies, so the individual should keep copies of receipts for a period of 2 years.
ADP will cover part of the cost for any Ontario resident with a valid Health Card that requires one of the following for at least six months of regular daily use:
The individual, along with the medical specialist will be required to complete an ADP form. For burnscar pressure garments, burn orthoses and extremity pumps, the specialist physician should be a member of a burn or lymphedema team registered with ADP. For lymphedema compression garments, the specialist must be a vascular surgeon, orthopedic surgeon, radiation oncologist medical oncologist, internist, paediatrician, plastic surgeon, physiatrist, or general surgeon.
The specialist will refer the individual to the appropriate APD registered authoriser who will assess the exact type of device needed and will complete the form. The authoriser will be able to indicate from which ADP registered vendor the device can then be purchased.
The vendor will bill ADP directly for 75% of the approved cost of the device. The individual will pay the remainder.
ADP also pays 75% of the cost of a replacement device under the following circumstances:
Maxillofacial Prosthesis
ADP covers part of the approved cost for any Ontario resident with a
valid Health Card who needs any of the following:
The individual, along with the medical specialist will be required to complete an ADP form. For a maxillofacial extraoral prosthesis, the medical specialist must be a doctor who is a specialist in plastic surgery, ophthalmology, oncology or otolaryngology. For a maxillofacial intraoral prosthesis, the medical specialist must be a doctor who specialises in this area such as a dentist.
The authoriser/vendor will complete the rest of the form and request the prosthesis. He will be billed for 75% of the approved cost. The individual will pay the remainder. All adjustments recommended by the medical specialist during the first three months are included in the cost of the prosthesis. ADP will pay part of the cost of a new maxillofacial extraoral prosthesis when the medical specialist attests the need due to a change in medical condition or body size.
Breast ProsthesisADP does not fund brassieres, temporary breast prostheses, silicone nipples or breast implants.
The individual along with the doctor will complete part of the form. The doctor will refer the individual to a registered ADP vendor. The vendor will bill ADP directly for 75% of the approved cost of the breast prosthesis. The individual will be responsible for the rest.
The vendor should provide a minimum two year written warranty guaranteeing the prosthesis against defects. The vendor should guarantee the fit of the prosthesis for at least two years, unless the individual’s size or medical condition changes. If this occurs, ADP will cover a portion of the cost of a new prosthesis upon the doctor’s recommendation.
A portion of the cost of an attachable breast prosthesis can also be covered under ADP. The doctor should look at the individual’s condition before prescribing this prosthesis. The fitter should provide the individual with a test patch to wear for one week to detect any reaction to the adhesive.
Adhesive strips are not recommended during the first year after a mastectomy or the first 6 months after radiation therapy or chemotherapy.
Ocular ProsthesisThe application form should be completed by the individual, and an ophthalmologist, family doctor or optometrist, after an exam. The doctor will refer the individual to a certified ocularist. This person, who is a staff member of an ADP registered vendor, will determine which type of artificial eye the individual needs, and will complete his/her portion of the form. The ocularist is also the person who will make the prosthesis.
Once the prosthesis is completed and the individual is satisfied with its fit and appearance, ADP will be billed for its portion and the individual will be responsible for the rest.
The vendor must provide a three month warranty for proper fit of the ocular prosthesis, and a one year warranty against discoloration and separation of the materials.
ADP will pay part of the cost of repair or replacement of an ocular prosthesis when it is no longer usable due to a change in medical condition or size of the eye socket. The change must be verified by the doctor.
Limb ProsthesisThe individual will need to make an appointment with an Amputee Team registered with ADP. Information on Team locations can be obtained through the same number used to obtain ADP application forms. The team consists of a physician, a prosthesist and a physiotherapist or occupational therapist. They will assess the individual’s needs and help decide which type of prosthesis best suits the individual’s requirements. The individual along with the team will complete the required portions of the application form.
The choice of components will affect the cost of the prosthesis. The individual should discuss this with the prosthesist. Before the prosthesist begins making the prosthesis, the individual will get a written estimate of the total cost of the prosthesis, along with the portion that ADP will pay for and the portion that the individual will be responsible for. ADP will help pay for the replacement of the socket of the prosthesis or any adjustments needed if the team agrees that it no longer fits your residual limb.
The individual should receive a written warranty that guarantees against breakage for six months and three months for satisfactory fit provided that the individual’s size or medical condition has not changed significantly. There may be other manufacturer’s warranties for component parts.
ADP covers a portion of the approved cost, rental, or replacement for any Ontario resident who has a valid Health Card, has a long-term respiratory problem and does not live in an institution, for the following Respirator Products:
Except for apnea monitors (available for infants only) and compressors, the above devices are covered for people of all ages. Medical criteria differ for each product. Before buying a respiratory product the individual should discuss the requirements with his / her doctor or qualified professional.
The individual, the doctor and an ADP registered vendor must each complete a section of the form. A medical exam is required. For Nasal CPAP products, the individual must be assessed by a doctor who works at a sleep clinic registered with ADP.
The following medical specialists may recommend a respiratory product that best suits the individual’s needs (except nasal CPAP) and can show the individual how to use it:
The vendor will bill ADP directly for a portion of the cost. The individual is responsible for the rest.
The amount of the cost that ADP pays varies. ADP will pay 75% of the approved cost for:
ADP will also fund 75% of the rental price up to a maximum amount for 6 months, and will lend ventilators from the Ventilator Equipment Pool (VEP).
ADP will contribute toward the cost of replacement if the equipment is no longer working and cannot be repaired.
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Visual Devices |
ADP pays a portion of the cost, lease or replacement of Visual Devices for any Ontario resident with a valid Health Card and that has long-term low vision or blindness that can’t be corrected medically, surgically or with ordinary eyeglasses or contact lenses. These devices include:
The individual may be eligible for up to:
The individual and the authoriser will complete the authorisation form. The authoriser will be an ADP registered ophthalmologist, optometrist, special teacher of the blind, orientation/mobility instructor, or other specialist, depending on the individual’s needs. The authoriser will also help the individual to decide which visual aid is best.
CCTV and computer-integrated equipment may be authorised by an ADP designated centre following an assessment. The ADP contribution for a brailler or typewriter can be used toward computer-integrated equipment.
Low-Technology Devices can be purchased from any ADP registered vendor. The vendor will bill ADP for up to 75% of the approved cost. High-Technology Devices and CCTV’s are sold or leased through ADP designated centres. The individual has 30 days to try out the visual aid, if he / she is not satisfied it can be returned.
If a visual aid needs to be replaced, the authoriser must write a letter to ADP explaining why. ADP may pay part of the costs. If the device is no longer working or cannot be repaired, ADP will contribute to the cost of replacement after a specific number of years.
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Mobility Devices |
ADP contributes to the cost of the minimum equipment essential for mobility and positioning for mobility for any Ontario resident who has a valid Health Card and needs a mobility aid for six months or longer, except if the equipment is to be used only at school or at work. The following is a list of eligible devices:
The individual should contact a health professional who is registered with ADP as an authoriser. The authoriser will assess the individual’s mobility and will determine eligibility for ADP funding. The individual and the authoriser both complete the application form. The individual may require a fee for the assessment.
If the device is approved, ADP will send a copy of the prescription and an approval notice that can be taken to an ADP registered vendor. The vendor will bill ADP 75% of the cost to a maximum amount. If the device is not approved, ADP will inform the authoriser and the individual of the reason.
ADP does not pay for maintenance or repairs. ADP may contribute to the cost of a new device if the individual’s ability or body size has changed or if the device has worn out. The individual must contact the authoriser and fill in a new application form.
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Incontinence Supplies - On January 1, 1999, the Easter Seal Society launched a new incontinence supply program for children and youth with disabilities. This replaced the previous benefit from the ADP. |
Community Care Access Centres (CCAC’s)
For seniors and people with disabilities in Ontario, the government also offers the services of Community Care Access Centres (CCAC’s). These centres were established to ensure access to and co-ordination of long-term care services such as:
There are with 43 Community Centres across the province, run by volunteer boards that have been established to handle both Home Care and Long-Term Care Placements Co-ordination Services. CCAC’s will:
CCAC’s will also provide up to date information on other services including volunteer-based community services available through the OCSA (e.g. Meals on Wheels and friendly visiting), supportive housing, attendant services, children’s treatment centres and other related community services.
Location and direct phone numbers can be obtained through the Ministry of Health INFOline, (416) 314-5518 or 1-800-268-1154. A complete listing of locations and phone numbers across Ontario has also been included in Appendix 2.
Ontario Community Support Association (OCSA)
The Ontario Community Support Association represents over 350 not-for-profit organisations in Ontario which, in association with the CCAC, provide community health and support services. Community support is based on a firm philosophy that values friendly, caring and personalised service, in order to enhance self esteem and promote independence. These services are available to those who cannot function independently due to an illness or limitation, or due to ageing.
The cost for each of the services available varies and financial aid is available. Cost and financial assistance, as well as eligibility can be discussed with a staff person at a local agency, or a local Community Care Access Centre (CCAC).
There are a number of care options available from the community agencies. Care options through the OCSA are available in over 300 centres throughout Ontario and are grouped under the following services:
These services are directed at reducing feelings of isolation, fostering friendship, creating experiences for young and old and offering escorted rides to essential appointments. These services include the following:
The Home Services help individuals live safely and securely on their own and provide assistance with everyday household activities. These include:
Caregiver services support family members and friends in their caregiving roles by providing therapeutic counselling and relief from their care duties.
Location and direct phone numbers for all OCSA Centres can be obtained
through the Ministry of Health INFOline, (416) 314-5518 or 1-800-268-1154.
A complete listing is also available on the OCSA internet Website at:
www.ocsa.on.ca
Clicking on the above link, will take you to the original information included in printed versions of this document. It is a Web page within the Ontario Ministry of Health's Web site.
If the link directly to the OHIP Office Locations doesn't work or has expired,
you can still find this information by searching the Government
of Ontario's Web site at:
www.gov.on.ca/MBS/english/common/search.html
Clicking on the above link, will take you to the original information included in printed versions of this document. It is a Web page within the Ontario Ministry of Health's Web site.
If the link directly to the Community Care Access Centre Locations doesn't
work or has expired, you can still find this information by searching the
Government of Ontario's
Web site at:
www.gov.on.ca/MBS/english/common/search.html