Refugee health

While cuts to refugee health care have negatively affected health outcomes for refugees, confusion surrounding the changes to the program has exacerbated barriers to access for patients, even for those with valid coverage.

The Interim Federal Health Program (IFHP), a federal program that provides temporary coverage for refugees in Canada, has undergone sweeping changes in the past year.¹ In that time, a relatively uncomplicated and comprehensive program has been replaced with one that is far more difficult to navigate and that requires additional administrative work on the part of health care facilities receiving refugees as patients. Our hope is that this article will help providers understand the changes to the IFHP, reduce confusion, and improve health outcomes for refugees and refugee claimants.

Classes of coverage

Before June 30, 2012, the IFHP had a single class of health insurance coverage for all categories of refugees. Hospital and physician services were covered, as well as some additional health benefits, including emergency dental and vision care, vaccinations, and medications similar to those provided by provincial social assistance formularies. These benefits were equivalent to what those on social assistance received. As of June 30, 2012, there are now 3 classes of IFHP coverage.

Expanded health care coverage

This class of coverage is available primarily for government-assisted refugees.² Government-assisted refugees are refugees whose initial resettlement is supported by the Government of Canada.³ The coverage provided is equivalent to that of the old IFHP, and, according to the Citizenship and Immigration Canada website, “The level of coverage provided through the IFHP for these benefits is similar to the level of coverage which may be provided by provincial and territorial governments to Canadians receiving social assistance.”⁴

Health care coverage

This is available for privately sponsored refugees and refugee claimants who are not from designated countries of origin (DCOs),² which are countries that have been deemed to be “safe” and therefore to not produce refugees under normal circumstances. Those eligible for “health care coverage” have coverage for hospital, physician, laboratory, and diagnostic services. Medications and vaccines are generally not covered, unless they are needed to prevent or treat a disease that poses a risk to public health or public safety—for example, medications for HIV or tuberculosis.

Public health or public safety health care coverage

This last class of coverage is available to failed refugee claimants and claimants from DCOs.² There are currently 35 countries on the list, and others can be added at the discretion of the federal government.⁵ The list includes Hungary, which until recently was one of the top refugee-producing countries for Canada, and Mexico. A full list can be found here: www.cic.gc.ca/english/refugees/reform-safe.asp.⁵ Claimants from these countries are not covered for physician visits, hospital visits, or medications, unless it is to prevent, diagnose, or treat a very limited number of conditions that are defined as being a threat to public health or public safety.⁶ These conditions include those that are nationally notifiable diseases.⁷ Note that not all infectious diseases are covered; for example, a typical community-acquired pneumonia or pyelonephritis would not be covered. Other conditions, even life-threatening illnesses, and routine antenatal or well-child visits will also not be covered under this new category.

The federal government has not clarified which clinical presentations or symptoms would justify an investigation to rule out an infection by a transmissible organism (and hence services being covered under the public health category), even if the eventual diagnosis is not a notifiable disease. Therefore, when calling the Blue Cross, it is important to highlight that the visit is to investigate a possible communicable disease—for example, evaluating a cough in order to rule out tuberculosis.

Effects of reduced coverage

The changes to the IFHP have drastically reduced coverage for many refugees. Adverse events as a result of these cuts include, for example, an accepted refugee claimant who had an avoidable emergency department visit and hospitalization following an asthma attack because she did not have coverage to pay for her bronchodilators.⁸ At the same time, we are seeing poor outcomes related to the confusion surrounding these new IFHP categories of refugees and the different levels of coverage. The lack of clarity and additional steps needed to navigate this system have resulted in physicians refusing to see refugees, despite their having valid IFHP documentation and coverage for the visits. Children and pregnant women are being turned away from clinics despite having valid coverage.⁸ Patients are being asked to pay up front of their visits despite having coverage. E–mails obtained from the CMAJ revealed that only 9 out of 33 walk-in clinics in Ottawa, Ont, were accepting refugees as patients, and in those cases in which refugees were seen, they were charged fees of up to $60.⁹ Refugees are being harmed by confusion almost as much as by the cuts themselves.

While we cannot directly and immediately influence federal policy, we can directly affect the lives of refugees in our respective practices. In order to best treat refugees under the current system, we must understand the classes of coverage and how to navigate the IFHP accordingly.

What to do when a refugee comes to your practice

• Register with the Blue Cross (888 614–1880) in order to bill for patients with IFHP coverage. You can register with the Blue Cross after seeing refugees and retroactively bill for the patients you have seen.

• If you are unsure, confirm the patient’s IFHP coverage when he or she arrives at your practice and contact the Blue Cross (866 614–1880) to confirm that the patient’s visit will be covered.

  • -Once registered, you can also obtain a secure password and check a patient’s IFHP coverage online without having to call the Blue Cross.

  • -Be aware that there have been cases of patients being wrongfully denied coverage by the Blue Cross, likely owing to confusion surrounding their status.

• Refugee claimants from non-DCOs should be covered for physician visits and for diagnostic services similar to those covered by provincial health plans.

  • -Medications or vaccines will only be covered if they are deemed necessary to prevent a threat to public health or public safety.

• Refugee claimants from DCOs will only be covered if their conditions pose a threat to public health or public safety.

  • - If the visit is to address a possible communicable disease, the refugee should be covered for the visit, diagnostics, and treatment if necessary.

  • - When discussing the case with the Blue Cross, highlight the communicable disease you are trying to evaluate based on the chief complaint.

• A summary of the types of coverage can be found at the Citizenship and Immigration Canada website: www.cic.gc.ca/english/refugees/outside/summary-ifhp.asp.¹⁰

To provide the best care for refugees within our current system, we must ensure that patients who have coverage receive medical attention and that they are not wrongfully turned away. For those who no longer have medication insurance, prescribe generic brands and offer samples if they are available; for those who no longer have medical coverage, consider if you are able to prorate charges to their income and means. While we continue to advocate for a full reversal of the cuts to the IFHP, it is important that we as a medical community continue to advocate for our patients as individuals in need of medical care.