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Welfare (Ontario Works) Law
(01 January 2016)

Chapter 4 - Benefits


  1. Important Explanatory Note
    (a) General
    (b) Supplements to Basic Assistance
    (c) Non-Discretionary Benefits
    (d) Discretionary Benefits
    (e) "Employment Assistance"
  2. Non-Discretionary Benefits
    (a) Overview
    (b) Health Benefits
    . Drug Card
    . Vision Items and Services
    . Eye Tests
    . Note re Dental Services
    . Medical Supplies
    . Medical Transportation
    . Assistive Devices Contribution and Assessments
    . Mobile Device Batteries and Repairs
    (c) Community Start Up and Maintenance Allowance (CSUMA)
    (d) Guide Dogs
    (e) Employment and Training Start up Assistance
    . Starting Full-time Employment
    . Starting or Changing Employment or Starting an Employment Assistance Activity
    . Provisions Mutually Exclusive
    (f) Up Front Child Care Benefit
  3. Extended Health Benefits
    (a) Overview
    (b) Extended Drug Card Where Employment-Related Disentitlement
    (c) Extended Health Benefits Where Income Ineligibility
    (d) Extended Drug Card Where Income Ineligibility, Pending ODSP Application and Specific Illnesses
    (e) Extended Health Benefits Where Income Ineligibility Caused by Payments under the 1986-1990 Hepatitis C Settlement Agreement
    (f) Extended Health Benefits Where Income Ineligibility Due to Employment Income
  4. Discretionary Benefits
    (a) Overview
    (b) Coverage
    (c) Extended Discretionary Benefits Where Income Ineligibility Due to Employment Income
    (d) Case Law
  5. Date of Benefit Entitlement

________________________________________



1. Important Explanatory Note

(a) General

When considering the supplements and benefits discussed in this chapter - and elsewhere in this Legal Guide - it is important to know how the particular item is categorized in welfare law. Categorization is important because it determines whether and when (ie. at what stage of the 'cheque' calculation) the value of a supplement or benefit can be reduced by chargeable (deductible) income and/or by overpayments owed by the recipient to ODSP or related programs.

Categorization is also important in a few situations in determining whether disputes over a supplement, benefit or service can be appealed through the primary Social Benefits Tribunal (SBT) system or not. This is because only decisions "affecting eligibility for or the amount of basic financial assistance" can be appealed to the SBT (see Ch.10: "Appeals and Other Remedies").

The key categories are "budgetary requirements" (BRs) and "basic (financial) assistance". Basically, BRs are the maximum amounts that welfare law allows for shelter and basic needs, which when reduced by chargeable (deductible) income (see Ch.6: "Income rules") - and increased by the value of any 'benefits' (see ss.2 and 4) - produces the monthly "basic assistance" figure.

If there are any overpayment assessments against the benefit unit then the "basic assistance" figure is further reduced by (up to) 10% (of the basic assistance amount) to produce (usually) the amount of that month's welfare cheque (or commonly these days, direct deposit) [Act s.20(1)]. Of course, if there are no overpayment assessments then the amount of "basic assistance" is (usually) the amount of the cheque or deposit. These concepts are discussed in more detail in Ch.1, s.5: "Overview: Main Concepts".

(b) Supplements to Basic Assistance

The first items to be considered are "supplements" - which includes supplements for special diet, pregnancy, advanced age and the northern supplement. These are discussed and explained in Ch.3 "Basic Assistance".

The value of these supplements is included within the calculation of "budgetary requirements". As such they are part of the total of budgetary requirements that is subject to reduction for chargeable income to produce the "basic assistance" figure. After that is done, the "basic assistance" amount (which contains within it the value of the supplement) can be further reduced by any outstanding overpayments.

As well, since BRs have a direct role in determining the amount of basic assistance, the decision to grant or refuse any of these supplements is appealable to the Social Benefits Tribunal.

(c) Non-Discretionary Benefits

These include the items covered in section 2 and 3 of this chapter: a variety of health benefits, community start-up and maintenance allowance (CSUMA), guide dogs allowance, employment and training start-up assistance and up-front child care assistance [Reg s.55].

"Non-discretionary" does not mean that they must be provided if simply requested, rather it means that there are defined eligibility criteria for them, which if met, give the applicant a mandatory entitlement to them.

Some of these are delivered to the recipient in the form of a financial addition to their cheque - like a supplement - and some are provided directly, for example in the form of a "drug entitlement card".

The value of non-discretionary benefits is not included within "budgetary requirements", and as such they are not subject to reduction for chargeable income. However, their value is still part of "basic assistance" [Act s.5(b)] that can be reduced by outstanding overpayments. This means that if chargeable income (applied to reduce BRs) reduces the assistance level down close to zero (but not at zero), the "benefit" will still be provided in full, subject only to any overpayment deductions.

That said - and just to confuse things - several of the complex "extended health benefit" provisions covered in s.3 below do incorporate the value of the "extended benefit" into the budgetary requirements calculation for sole purposes of extending health benefits eligibility during (usually) brief periods when a recipient is otherwise ineligible.

The decision to grant or refuse any non-discretionary benefit is appealable to the Social Benefits Tribunal.

(d) Discretionary Benefits

"Discretionary benefits" are items which may - or may not - be provided by the local welfare administrator as per local welfare policy (see s.4 below). Budgets for these items are limited as the province only supplies the delivery agent $8.75 per claimant per month for discretionary benefits.

These can include coverage for expenses associated with dental services, prosthetic appliances (for these see also the Ontario Assistive Devices Program), eyeglasses, vocational training, travel and transportation, moving, funeral and burial related expenses and others [Reg s.59].

The value of discretionary benefits is not included within "budgetary requirements", so they are not subject to reduction for chargeable income. However, they still are part of the basic assistance [Act s.5(b)] that can be reduced outstanding overpayments. This means that if chargeable income reduces the assistance level down close to zero (but not at zero), the "benefit" will still be provided, subject only to any overpayment deductions.

Despite their being included in "basic assistance", the decision to grant or refuse non-discretionary benefits is not appealable to the Social Benefits Tribunal [Act s.26(2)2].

(e) "Employment Assistance"

There is another category called "employment assistance", which in most circumstances is an involuntary requirement of welfare eligibility also known as "workfare". However, recipients and members of their benefit unit who are not required to engage in these "workfare" programs (and anyone in an ODSP benefit unit) may elect into these programs if they wish (see Ch.11 "Workfare").

Employment assistance services are not normally given a dollar value, and neither are they included within the calculation of either "budgetary requirements" or "basic assistance". As such they are not effected by either chargeable income or overpayment assessments.

Employment assistance decisions that do not affect eligibility for or the amount of basic assistance are not appealable through the SBT system.


2. Non-Discretionary Benefits

(a) Overview

The following non-discretionary benefits (each of which is discussed in turn below) are available - upon qualification - to each member of a benefit unit (unless otherwise specified) who is in receipt of welfare assistance [Reg s.55]:
  • Health Benefits (drug card, dental and vision items and services for dependent minors, diabetic supplies, surgical supplies, medical-related transportation, assistive devices expenses and assessment, mobility-device batteries);

  • Community Start-up and Maintenance Allowance ("CSUMA");

  • Guide Dog expenses;

  • Full-time Employment-related Start-up Benefit;

  • Up-front Child Care expense.
Note that the 'winter clothing' and 'back-to-school' allowances were terminated in July 2008 as part of the introduction of the Child Tax Benefit program.

While these benefits are available to all members of a benefit unit receiving welfare assistance, they can also be "extended" - in whole or part - to others in some circumstances. Such extensions apply to persons who have applied for ODSP eligibility, who are receiving payments under the Hepatitis C Settlement Agreement and those who have become temporarily ineligible by reason of excess income. These "extensions" are explained in s.3 below.

(b) Health Benefits

. Drug Card

Welfare recipients receive, on a monthly basis, a "drug card" which - when presented to drug-providers - vouches for payment of doctor-prescribed drugs listed by the Ministry of Health and Long-Term Care. The card does not cover "co-payment" dispensing charges.

The drugs covered by a 'drug card' are listed in the Ontario Drug Benefit Formulary.
Note:
Persons needing a "drug card" who have neither ODSP eligibility or ODSP 'extended health benefit' coverage [see s.3 below] may also establish drug coverage eligibility if they receive "home care services" [Reg 201/96, s.2(1)1 under the Ontario Drug Benefit Act]. Application for home care services (typically assistance with the activities of daily living for disabled persons) may be made through your local Community Care Access Centre or 'CCAC'.
. Vision Items and Services

For members of the benefit unit who are under 18 years of age, and minors in temporary care [see Ch.2, s.6], the cost of Minister-approved vision items and services [see also 'Eye Tests', below].

. Eye Tests

For all members of the benefit unit, "periodic oculo-visual assessments" at a rate of $39.15 each [Reg s.55(1)paras.(1.1), s.55(1.0.0.1)]. Such assessments are only available if the member of the benefit unit has not had such an assessment (or a major eye examination) within the past 24 months, and as long as such assessment is not OHIP-covered.

References to "major eye examinations" and "periodic oculo-visual assessments" include where they are performed by an optometrist or by a physician.

. Note re Dental Services

Up to 01 January 2016, dental services for members of the benefit unit under 18 years of age, and for children receiving temporary care assistance, were also covered as a non-discretionary health benefit. As of that date such services are available through this Ontario government program Healthy Smiles Ontario.

Children in Indian Bands will continue to receive dental services as a welfare benefit until the end of 2016 (presumably at which point some other arrangements will be made).

. Medical Supplies

The cost of diabetic and surgical supplies (including dressings), as long as such cost is not otherwise reimbursible to the member.

. Medical Transportation

The cost of transportation required for medical treatment, as long as such cost is not otherwise reimbursible to the member and as long as the expense is $15 or more per month.

When very frequent medical appointments are required the administrator may provide the member with transit tickets, tokens or a monthly pass.

In Director, ODSP v Billotte (Div Ct, 2009) the court held that voluntary attendence at a day program, although of benefit to the recipient, did not constitute "medical treatment" to justify a medical transportation allowance.

. Assistive Devices Contribution and Assessments

The province runs a program under the Ministry of Health and Long-Term Care called the "Assistive Devices Program" (ADP). It provides partial subsidization for a variety of illness or disability-related assistive devices such as motorized wheelchairs ("mobies"), artificial limbs, etc. Welfare will pay the "consumer contribution" toward such purchases if they are otherwise approved under the ADP for the member of the benefit unit.

Similarly, welfare will pay the expense for an assessment - to a fixed amount - to determine if ADP eligibility is merited - as long as such cost is not otherwise covered.

. Mobile Device Batteries and Repairs

The cost of batteries and necessary repairs for mobile devices, as long as such cost is not otherwise reimbursible to the member.

(c) Community Start Up and Maintenance Allowance (CSUMA)
Note:
This benefit used to be known as the "CSUA" (Community Start-Up Allowance" as it only applied to the establishment of a new household. It is important to note that it has been amended now to be available also to "maintain" an existing household if the pre-conditions are met.
An amount, paid no more frequently than every 24 months and if the recipient requires it, to establish a new residence (even if outside of the administrator's geographic area) or remain in his existing residence, if any of the following conditions are met:
  • the recipient is being discharged from "an institution which provided for his or her basic needs and shelter" (eg. hospital, homeless shelter, residential substance abuse recovery facility, women's shelter, jail or penitentiary, long-term care home) (see Ch.3 "Assistance: Institutional Residents");
  • it would be "harmful to (the recipient's) health or welfare to remain in his or her current place of residence";
  • the recipient has been evicted from his or her current residence;
  • the recipient "has received a notice of termination or a notice to quit with respect to his or her tenancy or a final demand for payment under a mortgage and has satisfied the administrator that, if a payment is made, he or she will not be evicted from his or her current residence"; or
  • has had any energy source (ie. heat, light, cooking, etc), water and sewage, or rental of a furnace or hot water heater discontinued, or where notice of impending discontinuance has been given, and where the payment of arrears will result in the resumption or prevention of discontinuance, as the case may be.
The amount of the CSUMA shall not exceed $799 for a single recipient or $1500 for a recipient with dependent minors, subject a discretionary increase in that same amount by the administrator if "exceptional circumstances" exist.

There is no eligibility for a CSUMA if it has been already paid out in the 24-month period under any other OW (welfare) or ODSP CSUMA entitlement, except that where the maximums have not yet been exceeded additional payments may be made to the maximums (or as such maximum may be extended by the administrator in "exceptional circumstances", above).

(d) Guide Dogs

If a member of the benefit unit has a guide dog, an amount not exceeding $78 for the care of the guide dog.

(e) Employment and Training Start up Assistance

. Starting Full-time Employment

If a recipient, spouse or a dependent adult (who is not attending school full-time) of the benefit unit begins full-time employment, an amount reasonably necessary for the person to begin the full-time employment, up to a maximum in any twelve-month period for any member of $500 [Reg 55(1)(5.1)]. "Full-time" employment is defined as "30 hours or more of paid employment per week."

However, such assistance is only available to the recipient of the benefit unit where the recipient has been receiving assistance for three months or more (meaning it is available to dependents anytime).

. Starting or Changing Employment or Starting an Employment Assistance Activity

Similarly, if a recipient, spouse, dependent adult (who is not attending secondary school full-time) or a dependent child who has received an Ontario Secondary School Diploma or its equivalent "begins or changes employment or begins an employment assistance activity", an amount reasonably necessary for the person to begin the new employment or activity, up to a maximum in any twelve-month period for any member of $253 [Reg 55(1)(6)].

If assistance has already been paid under this category under the similar ODSP provision, the maximum allowance provided for here shall not be exceeded by any further allowances paid under this welfare provision.

. Provisions Mutually Exclusive

The above two provisions are mutually exclusive, and assistance shall not be provided under both of them with respect to the same employment or employment assistance commencement [Reg 55(1.0.4)].

(f) Up Front Child Care Benefit

Assistance is available for a recipient, spouse included in the benefit unit, dependent adult or dependent child who, in the opinion of the administrator, requires up-front child care fee assistance in order to begin, change or maintain their employment or employment activity [Reg s.55(1)7].

The maximum amount payable for this annually is the same amount as the monthly child-care income deduction set out in s.49 (see Ch.6 "Income Rules"). This amount is, for each child - provided that such amounts are not otherwise reimbursible to the member - either:
  • the actual amount paid to a licensed Day Nursery; or

  • $600.
No up-front child care benefit is payable to child-care provided by a member of the benefit unit.

The effect is to provide the assistance for a month's pre-payment, but only once annually. Similar up-front child care assistance is available under the ODSP system, but the total amount from both programs shall not exceed the maximums set out above.


3. Extended Health Benefits

(a) Overview

Welfare law recognizes the disruption that can be caused by abrupt termination of some health care benefits, particularly drug coverage. Therefore, in the following circumstances, some or all health benefits are "extended" despite the benefit unit's (usually temporary) ineligibility for assistance. These provisions can be quite complicated and in some cases duplicate each other.

(b) Extended Drug Card Where Employment-Related Disentitlement

Drug card eligibility shall continue to be provided to a member of a benefit unit through any period of temporary cancellation of assistance brought about by failure of the member to make reasonable efforts to obtain and maintain employment (including quitting or being fired without cause), or unjustified failure to participate in employment assistance activities (see Ch.11 "Workfare"), provided that the member [Reg s.55(4)]:
  • is otherwise eligible for assistance, and
  • requires the drugs "for a serious illness or serious health condition".
These temporary cancellation provisions are discussed at length in Ch.11 "Workfare: Non-Compliance".

(c) Extended Health Benefits Where Income Ineligibility

Eligibility of a benefit unit's members for all of the "Health Benefits" [see s.1(b) above] shall be "extended" for any period of months in which ineligibility is caused by the benefit unit's income exceeding budgetary requirements continues (see Ch.6 "Income Rules"), if all of the following conditions apply [Reg s.57.1]:
  • the benefit unit or the member received assistance in the previous month ("assistance" includes benefits);
  • the benefit unit or member are otherwise presently eligible for assistance and the benefit/s; and
  • when the value of the benefit/s is added to "budgetary requirements" of the benefit unit, the assistance amount after chargeable income is greater than zero (ie. where the "new" budgetary requirements, which count the value of the health benefits, are greater than chargeable income).
For a related provision, see also "Extended Health Benefits Where Income Ineligibility Due to Employment Income" [s.2(f) below].

(d) Extended Drug Card Where Income Ineligibility, Pending ODSP Application and Specific Illnesses

Eligibility of a benefit unit's members for a drug card [see s.1(b) above] shall be "extended" for each month's ineligibility that is caused by the benefit unit's income exceeding budgetary requirements (see Ch.6 "Income Rules") if all of the following conditions are met [Reg s.58]:
  • the benefit unit or member are otherwise presently eligible for assistance and the benefit/s;
  • when the value of the drug card benefit/s is added to "budgetary requirements" of the benefit unit, the assistance amount after chargeable income is greater than zero (ie. where the "new" budgetary requirements, which include the value of the drug benefit, are greater than chargeable income);
  • the recipient or their spouse has an application filed for ODSP eligibility and that application "has not been finally disposed of" (this is interpreted to count the period for appeals to be filed, and the time required to complete them), and no prior eligibility refusals under ODSP or FBA have occured to the present ODSP applicant; and
  • the recipient or their spouse has a condition listed in s.8(2) of Reg 552 under the Health Insurance Act (HIV, schizophrenia, hemophilia and some other conditions)
For a complete list of the specific 'conditions' which trigger eligibility above, see s.8(2) of Reg 552 under the Health Insurance Act.

Regulation 552: Health Insurance Act

Note that while this OHIP provision sets out both the conditions, and the specific drugs which are covered by OHIP, it is only the conditions listed which trigger the extended drug coverage. The drug card received covers all drugs normally covered by the card, regardless of whether they are listed in s.8(1)(5)(ii).

(e) Extended Health Benefits Where Income Ineligibility Caused by Payments under the 1986-1990 Hepatitis C Settlement Agreement

Eligibility of a benefit unit's members for all of the "Health Benefits" [see s.1(b) above] shall be "extended" for any month" of ineligibility that is caused by the benefit unit's income exceeding budgetary requirements by reason of a 'loss of income' payment or a 'loss of support' payment under the 1986-90 Hepatitis C Settlement Agreement (see Ch.6 "Income Rules") if all of the following conditions are met [Reg s.58.1]:
  • the benefit unit or member are otherwise presently eligible for assistance and the benefit/s; and
  • on April 1, 1999 the recipient of the Settlement payment was a member of a benefit unit under the Ontario Works Act, ODSP or FBA (Family Benefits Act).
Note that there is no requirement here for an amended "budgetary requirements" calculation adding the value of the health benefits.

(f) Extended Health Benefits Where Income Ineligibility Due to Employment Income

Eligibility of a benefit unit's members for all of the "Health Benefits" [see s.1(b) above] shall be "extended" for six months when ineligibility for assistance is caused by the benefit unit's income exceeding budgetary requirements by reason of employment income [Reg s.57.2] (see Ch.6 "Income Rules"), if all of the following conditions are met:
  • the benefit unit or member are otherwise presently eligible for the benefit/s and assistance;
  • the benefits are not otherwise recoverable under an employment benefit plan; and
  • the member is not eligible for extended Health Benefits under s.2(c) above: "Extended Health Benefits Where Income Ineligibility" (this just requires that the s.2(c) extension be applied first);
Extended benefits under this provision [Reg s.57.2] last for six months, commencing on the first day of income ineligibility.

This period may be further extended by the administrator for another six months if "not to do so may be harmful to the health of a member of the benefit unit or may jeopardize the employment of a member of the benefit unit." During this further extension however drug coverage is reduced.


4. Discretionary Benefits

(a) Overview

Welfare administrators may provide additional benefit coverage, at their discretion, for below-listed items and in amounts as they see fit. These benefits are funded by the province at a rate of $8.75 per claimant per month, and local welfare administrators should have adopted policies for these discretionary benefits.

Such "discretionary benefits" can be provided to members of benefit unit receiving welfare (Ontario Works) - and also to those receiving ODSP income support, grandparented FBA recipients, those receiving ODSP assistance as "children with severe disabilities" under ODSP Reg.224/98, and minors in temporary care (see Ch.2, s.6: Claimants: Minors in Temporary Care) [Act s.8; Reg s.59(4)(4.1)]).

(b) Coverage

Administrators may - but do not have to - provide coverage in any of the following categories. Contact your local administrator for details as to local coverage.

"Discretionary benefits" may include [Reg s.59]:
  • the cost of dental services;
  • the cost of one or more prosthetic appliances, including eye-glasses;
  • the cost of vocational training and retraining;
  • the cost of travel and transportation;
  • the cost of moving;
  • the cost of a funeral and burial and the extraordinary costs of transporting a deceased person;
  • any other special service, item or payment authorized by the Director.
(c) Extended Discretionary Benefits Where Income Ineligibility Due to Employment Income

Eligibility of a benefit unit's members for some discretionary benefits shall be "extended" for any month when ineligibility for assistance is caused by the benefit unit's income exceeding budgetary requirements by reason of employment income [Reg s.57.2] (see Ch.6 "Income Rules"), IF:
  • the benefit unit or member are otherwise presently eligible for the benefit/s and assistance;
  • the benefits are not otherwise recoverable under an employment benefit plan;
These extended discretionary benefits include:
  • the cost of dental services provided to members of the benefit unit other than dependent children;
  • the cost of eye-glasses for members of the benefit unit who are 18 years of age or older;
  • the cost of one or more prosthetic appliances, other than eye-glasses, for members of the benefit unit; and
  • "any other special service, item or payment authorized by the Director if the service or item are related to the health of a member of the benefit unit or the payment is for the benefit of the health of a member of the benefit unit."
(d) Case Law

Discretionary benefits are not appealable to the Social Benefits Tribunal [Act s.26(2)2], though they may be subject to judicial review for such things as legal error, procedural error in the decision-making process used, or violations of the Canadian Charter of Rights and Freedoms (see Ch.8 "Procedures and Appeals").

In Babineau v Peel Region [1995] OJ # 2100 (QL) (Div Ct) an applicant argued for broad unspecified dental coverage without providing the administrator any evidence by which it could 'pre-approve' the specific procedure sought. The court dismissed the application, deciding that it lacked jurisdiction to hear the matter as no statutory power of decision had yet been exercised in the circumstances. The result might have been different if the applicant had co-operated with the administrator at least to the point of getting a specific refusal to a specific, documented request.

In Simon v Metro Toronto [1993] OJ #101 (QL) (Div Ct) the judicial review applicants sought to challenge a policy decision of Metro Toronto to discontinue coverage for last month's rent deposit under the old General Welfare Act category of "special assistance", which is roughly equivalent to the present "discretionary benefits". The court refrained to do this, treating political funding decisions as not 'justiciable' by the courts. The decision reflects a long-standing reticence by the courts to second-guess the exercise of political spending powers, which they consider to be a core area of politics. The court suggested that a tort remedy (likely Charter tort: see Ch.10 "Appeals and Other Remedies") might be more appropriate, though current Charter tort jurisprudence is not encouraging.


5. Date of Benefit Entitlement

This issue, referred to as "date of grant" when considering primary ODSP eligibility, is discussed at length in Ch.8, s.3(d): "Applications and Procedures: How and When Welfare is Paid: Retroactive Eligibility". In that section I have included a case note on the recent Smith v ODSP (Div Ct, 2008) case. That case - while relevant to establishing a main eligibility "date of grant" prior to the date that the ODSP application was completed (ie. before the DDP forms were filed), was in fact a case about retroactive special diet allowance (based on special diet rules as they were before the restrictions imposed in November of 2005). Smith provides some guidance as to discretionary factors that the administrator may apply in granting benefits retroactively (that is, if the 'entitlement date' for the particular benefit is not determined plainly by statute or regulation, as it now is with the new special diet regime).

Anyone considering seeking retroactive benefits (ie. before the date that they applied for them), should review that case carefully.
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