Not all lab tests are covered by OHIP. Here’s what you need to know
OHIP #OHIP
Finally heading out for that blood test after two-and-a-half years of delay during the height of the pandemic? You may be surprised to know that not all such tests are covered under OHIP.
Despite claims on social media to the contrary, Ontario’s Ministry of Health says there have not been any recent changes to the list. But there are some tests that you do need to pay for out of pocket.
The Star breaks down why some tests are covered and others aren’t.
Should I expect to pay for my blood tests?
According to Ministry of Health spokesperson Bill Campbell, there have not been any recent changes to tests that are covered under the Ontario Health Insurance Plan (OHIP) list of insured lab tests “that may have led to a patient being charged.” If you think you’ve been charged for something that should have been covered you can contact:1-888-662-6613, or protectpublichealthcare@ontario.ca.
Lab-test provider LifeLabs added in a statement on its website that “there have not been any laboratory tests delisted (i.e. removed with no replacement test) in the last five years under the Ontario Health Insurance Plan” list of lab services.
What kinds of tests are not covered?
Not every single test is covered under OHIP. What’s covered and what isn’t sometimes depends on the individual patient.
“Insured patients can access medically necessary laboratory services at a hospital, community, or public health laboratories. There are certain criteria that need to be met in order for those services to be covered,” the ministry’s Campbell added.
For example, “in-patients and outpatients of hospitals are entitled to laboratory tests/services without charge if medically necessary,” he said.
There are some tests that are eligible for OHIP coverage outside of a hospital from certain providers, but they may include “specific eligibility criteria for the tests as well,” he added.
For example, a blood test called Prostate Specific Antigen (PSA) Testing is covered for patients with diagnosed or suspected prostate cancer, said Michelle Hoad, CEO of the Medical Laboratory Professionals’ Association of Ontario, which represents laboratory professionals.
If someone who doesn’t qualify wants the test, it costs about $33, according to a publicly available fee schedule from Grey Bruce Health Services.
Some prostate cancer awareness advocates have called for this to be covered for everyone to increase early detection, while other experts say it doesn’t provide a lot of value as a general screening tool.
Hoad added that, due to the pandemic, some people may have put off blood tests. Now that they are getting them, they may be surprised to discover not all of them are covered.
“I think what’s starting to happen is that as more people are going in and testing is resuming, people are now recognizing that there is a charge for some tests — that has not changed,” she said.
A document called the Schedule of Benefits for Laboratory Services lists the specific tests that are eligible for OHIP coverage in a community setting (not a hospital) from providers who have an agreement with the Ministry of Health, Campbell said. A list of blood tests that are not covered is not available, he added.
What are some examples of tests that aren’t covered?
Dr. Wendy Levinson is chair of Choosing Wisely Canada, a campaign that tries to encourage conversations between physicians and patients about “whether tests and treatments are useful and appropriate and/or may be unnecessary or could even be harmful” by triggering a “cascade” of further tests and possible procedures.
She said what’s right for one person may not be for another, and also that some tests are just outdated, or not providing useful information — although the campaign does not have anything to do with actually deciding what’s covered under OHIP.
An example is testing for vitamin D levels in the general population — a test that is only covered under very specific circumstances. For those who aren’t covered, it costs about $37, according to the Grey Bruce Health Services fee document.
Other changes have been made in the last decade for tests that are not covered unless patients meet certain requirements.
In 2019, some procedures and services were delisted from OHIP, including reducing coverage for CT and MRI scans on hips and knees, earwax removal, and urine pregnancy tests.
This came out of an order by an arbitration panel settling a contract dispute between the province and the Ontario Medical Association, (which represents doctors), that required eliminating about $460 million in services that were no longer medically necessary or worthwhile.
In 2012, the Physicians Service Agreement, which is a contract between doctors and the province, there were changes to remove some blood tests from OHIP that were deemed unnecessary.
OHIP coverage for folate testing was changed because folate deficiency is considered rare in Canada and officials wanted to curb unnecessary testing, according to information from the province published in 2012. The test is still covered for those who meet very specific criteria.
Who decides what is covered?
The Ontario Health Technology Advisory Committee — a committee of Health Quality Ontario’s board of directors, under the umbrella of Ontario Health — offers guidance around what services are covered by OHIP.
The body makes recommendations to the ministries of health and long-term care on what services and devices should be funded by OHIP, according to Health Quality Ontario’s website.
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