This bulletin provides important reminders, policy clarifications and other information regarding fertility services and the requirements under the OFP.

To: Fertility Clinics and Other Providers of Fertility Services in Ontario
Category: Fertility Clinics
Written by: Health Services Branch, Ontario Health Insurance Plan Division
Date issued: October 7, 2020

Disclaimer: This bulletin is a general summary provided for information purposes only. In the event of a conflict or inconsistency between this bulletin and the TPA, applicable legislation and/or regulations, the TPA, legislation and/or regulations prevail.

Submitting Eligibility Codes (B602A) for funded In Vitro Fertilization (IVF) services

Funded IVF Services are intended for patients who are preparing to undergo an embryo transfer for the purposes of conception. The B602A eligibility code is to be submitted when the patient has signed the consent forms, and there is intent to treat (i.e., intent to proceed with a Funded IVF Cycle).

The Primary IVF Patient must be under the age of 43 at the time their eligibility is checked through the submission of the B602A code, immediately prior to the start of their treatment. B602A should not be submitted to avoid patients “aging out” of the program or otherwise becoming ineligible.

The ministry understands that there may be a delay between the eligibility check and start of treatment (i.e., when the first funded service is received) to allow clinics to manage their schedules, wait lists, etc., and that the length of this delay may vary based on individual patient circumstances. However, the ministry expects clinics to take steps to limit this time frame as much as possible, and to be prepared to explain their rationale for allowing longer time frames in specific patient circumstances.

Funded embryology services under the OFP

As indicated in the OFP Transfer Payment Agreement (TPA), embryology services required to fertilize and culture embryos are considered Funded IVF Services. Additionally, any or all of the operating costs-including costs of the premises, equipment, supplies and personnel-required to perform all aspects of the Funded IVF Services are also Funded IVF Services. Therefore, although the method and type of equipment used to perform embryology services required to fertilize and culture embryos may vary between clinics, patients participating in the program cannot be charged for these services.

For example, OFP patients cannot be charged for incubator systems used to culture and grow embryos, regardless of whether clinics choose to use standard incubators or advanced time-lapse incubator systems such as Embryoscope. Patients also cannot be charged if clinics choose to use specialized equipment or supplies to perform funded embryology services, including specialized embryo culture media such as EmbryoGlue, or specialized methods of interpreting ultrasounds such as Matris.

Requirements for satellite and sub-contracted clinics

Under the Transfer Payment Agreement (TPA), funded clinics are permitted to sub-contract the provision of Funded IVF Services to other entities, such as unfunded community clinics or physicians. The purpose of permitting sub-contracting arrangements is to make funded IVF more accessible for patients by allowing them to receive Funded IVF Services (except for oocyte retrieval and embryo transfer) closer to home. These arrangements are also intended to improve continuity of care by permitting community physicians, where possible, to accompany their patients to funded clinics to receive funded IVF, rather than having their care transferred to a new physician associated with a funded clinic. In addition, sub-contracting arrangements must set out the remuneration to be paid, and in the case of physician services, must set out a dispute resolution process.

Sub-contracting arrangements are not to be used for the purpose of creating or supporting a practice that requires referrals of private pay patients by community physicians in order to enter into a sub-contracting arrangement that funds those physicians to provide components of Funded IVF Services. Not only would such a practice potentially impede patient access to publicly-funded IVF, but clinics should be aware that it may, in some circumstances, constitute a conflict of interest under the TPA.

Billing requirements for OFP-funded vs OHIP-insured services

Physician services for, and physician, hospital and laboratory services provided in support of Artificial Insemination/Intra-Uterine Insemination (AI/IUI), IVF, and Fertility Preservation (FP) are not OHIP-insured services. Claims for these services are not payable by OHIP and should not be submitted to OHIP for payment under any circumstances. This includes any physician service listed in the Schedule of Benefits for Physician Services that is performed for or in support of AI/IUI, IVF or FP, including: assessments/consultations; point of care laboratory testing (e.g., blood work) and ultrasounds. This applies to services rendered as part of cycles funded under the OFP as well as cycles paid for privately by patients.

Physician services related to diagnosing infertility and monitoring fertility not related to IUI or IVF (e.g., diagnosis, cycle monitoring to support natural conception through timed intercourse, etc.), including physician visits/exams/assessments/consultations and imaging/testing, remain OHIP-insured and claims for these services can be submitted to OHIP.

For additional information related to OHIP Claims for Fertility Services and the Ontario Fertility Program, please see INFOBulletin #12005.

"Administrative" or "Block/Annual" fees for unfunded/uninsured services

It has come to the ministry’s attention that some OFP-funded clinics are charging patients “administrative” or “block/annual” fees in association with their funded fertility treatment.

Under the OFP TPA, patients cannot be charged for any Funded Services provided under the program, and funded clinics cannot require the purchase of any unfunded ancillary services as a condition of accessing Funded Services. In accordance with the Commitment to the Future of Medicare Act (CFMA), patients also cannot be charged for any OHIP-insured services.

The ministry does not regulate charges by physicians for uninsured/unfunded services. Patients are responsible for any costs associated with these services, and the OFP TPA does not preclude clinics from charging patients for these services, either in the form of a block or annual fee or on an individual service basis.

However, these fees must be presented to patients as optional (i.e., a patient’s decision to decline payment of these fees will not impact their ability to access OFP-funded services) and cannot include costs for any funded/OHIP-insured services. For example, these fees cannot include costs for the planning, preparation, or administration of Funded Services, as these are listed in the TPA as common elements of OFP-funded services.

Clinics should review and be familiar with definitions of Funded Services and their common elements listed in the TPA to ensure that patients are not charged for these services. Clinics should also review any patient information materials related to fees and ensure that it is clearly indicated that fees are not mandatory and are specifically for uninsured/unfunded services.

As a reminder, the College of Physicians and Surgeons of Ontario (CPSO) is responsible for regulating charges by physicians for uninsured services in Ontario, including block fees. The CPSO, in accordance with regulations under the Medicine Act, has established guidelines for physicians with respect to charging patients for uninsured services which are set out in their policy entitled “Uninsured Services: Billing and Block Fees”.

According to the CPSO policy in place at the time of publication, physicians who provide uninsured services should make sure that their fees are reasonable, that patients understand their options when they are offered such services, and that patients are given enough information to make an informed choice about receiving and paying for such services.

Important definitions and interpretation of complex scenarios

The ministry appreciates that due to the complex nature of fertility services, complicated patient scenarios may arise. In some cases, patients will not be eligible for funding under the requirements of the OFP. If clinics are unsure about whether a particular scenario is in compliance with the TPA and OFP requirements, clinics are encouraged to contact the OFP for clarification at fertilityprogram@ontario.ca.

Although OFP staff can provide general assistance to clinics in interpreting the TPA, it is ultimately the responsibility of the funded clinic to adhere to the TPA provisions as a condition of funding. Therefore, funded clinics should ensure that they have read and are familiar with the program rules and requirements as set out under the TPA.

Clinics may also wish to review the following definitions:

Definition Meaning under the OFP
Primary IVF Patient Person who will undergo the embryo transfer and is trying to get pregnant.

It is the Primary IVF patient’s health card number that is used to check eligibility for the program and is used for all billing for a Funded IVF Cycle.
Secondary IVF Patient Person who is receiving any part of the Funded IVF Services but is not preparing to undergo an embryo transfer (e.g., egg/sperm donor).

 

Must also have a valid Ontario health card in order to receive funded services.
Surrogate Person who is trying to get pregnant and is intending to surrender the child at birth to the Intended Parent(s).

When a surrogate is being used, the Surrogate is always the Primary IVF Patient.
  Person who is intending to take custody of the child at birth from the Surrogate.

At least one Intended Parent must have a valid Ontario health card in order for a Surrogate to receive funded services.

Policy clarification: surrogates/gestational carriers

Under the OFP, eligible patients are entitled to receive one Funded IVF Cycle per lifetime, with one additional Funded IVF Cycle per lifetime if acting as a Surrogate (please refer to definition above).

Funded IVF Cycles are always tracked through the Primary IVF Patient (please refer to definition above). Therefore, in the case of surrogacy, the Surrogate is always identified as the Primary IVF Patient, and only the Surrogate's Ontario health card is used in the eligibility check fee code submitted to the ministry.

In a scenario where a patient has received a Funded IVF Cycle acting as a Surrogate through the OFP, they are only entitled to receive a second Funded IVF Cycle if it is for the purpose of building their own family. This patient would not be eligible to receive another Funded IVF Cycle acting as a Surrogate, regardless of whether they are acting as a Surrogate on behalf of the same Intended Parent(s) or on behalf of different Intended Parent(s) who have never accessed a Funded IVF Cycle under the OFP.

Should Intended Parent(s) wish to proceed with IVF using a Surrogate who has previously received a Funded IVF Cycle as a Surrogate, the Intended Parent(s) would be required to pay privately for the IVF service. Please also note that an Intended Parent may not be a Surrogate in the same Funded IVF Cycle.

Eligibility requirements for secondary IVF patients

Other people participating in a Primary IVF Patient’s Funded IVF Cycle (such as egg/sperm donors) are designated as “Secondary IVF Patients.” In order to receive funded services as part of a Primary IVF Patient’s Funded IVF Cycle, Secondary IVF Patients must meet the eligibility requirement of having a valid Ontario health card. There are no age limitations for Secondary IVF Patients or Intended Parent(s), and there is no limit to the number of Funded IVF Cycles that Secondary IVF Patients can participate in.

In a scenario where an individual seeking to participate in a Primary IVF Patient’s Funded IVF Cycle does not have a valid Ontario health card and receives any services (e.g., egg/sperm retrieval) in support of the Primary IVF Patient’s Funded IVF Cycle, these services are not funded under the OFP. In these cases, the Primary IVF Patient/Intended Parent(s) have the option to pay privately for any services rendered to that individual in support of their Funded IVF Cycle. Paying privately for services rendered to an individual who does not have a valid OHIP card does not invalidate a Primary IVF Patient’s eligibility for a Funded IVF Cycle under the OFP. However, in the case of surrogacy, at least one Intended Parent must have a valid Ontario health card in order for a Surrogate to receive a Funded IVF Cycle.

CFAS and choosing wisely recommendations for fertility services

In partnership with Choosing Wisely, the Canadian Fertility and Andrology Society (CFAS) has developed recommendations regarding interventions in the context of fertility treatment. Additional information about these recommendations and how they were developed is available on the Choosing Wisely Canada website.

Notifying the ministry of a clinic sale, transfer of ownership or relocation

Any sale or transfer of ownership of a Fertility Clinic participating in the OFP requires approval from the ministry for the TPA to continue with the new proposed Recipient. Requests for such approval must be sent to the ministry with at least 60 days’ notice by submitting a formal written request (letter is recommended) via email to fertilityprogram@ontario.ca.

The approval of such requests is at the sole discretion of the ministry, and both the current and proposed Recipient will be required to agree to the terms and conditions of the ministry’s Consent to Assignment and Consumption Agreement.

Relocation requests for Fertility Clinics participating in the OFP also require ministry approval and must be submitted with at least 60 days notice by submitting a formal written request to fertilityprogram@ontario.ca. If the ministry approves the new location, the TPA will be updated with the new address.

For additional information related to the OFP’s policies for Sale/Transfer of Ownership or Changing Locations, please see INFOBulletin #12013.

Managing clinic budgets and reconciling billings

Fertility clinics participating in the OFP are responsible for managing costs and the provision of services within the approved budget(s) specified in their TPA, without the expectation that funding will be reallocated in any given fiscal year.

The ministry also encourages clinics to monitor their monthly Remittance Advice (RA) reports and reconcile their billings on a timely basis in order to manage their budgets and avoid situations where OFP claims may become stale dated.

Keywords/tags

Ontario Fertility Program; OFP; Fertility Clinics; In Vitro Fertilization; IVF; Artificial Insemination; AI; Intra-Uterine Insemination; IUI; Fertility Preservation; FP; Assisted Reproductive Technology; ART.

Contact information

Please direct any inquiries regarding the information provided in this INFOBulletin to the OFP.

For general information regarding INFOBulletins, please email the Service Support Contact Centre or call 1-800-262-6524. You can also find INFOBulletins online on the Ministry of Health website.