Ontario is undertaking significant reforms to strengthen primary care access. One of the most consequential changes for nurse practitioners (NPs) is the planned ability to bill the Ontario Health Insurance Plan (OHIP) for primary care services beginning April 1, 2026. This shift does not happen in isolation: it dovetails with the province’s new primary-care framework under Bill 13, the Primary Care Act, 2025. It is also connected to a federal policy interpretation under the Canada Health Act, confirming that medically necessary “physician-equivalent” services provided by regulated professionals (such as NPs) must be publicly funded by provinces and territories on that same date.
Bill 13 at a Glance: A Framework for Primary Care
Bill 13, the Primary Care Act, 2025, articulates Ontario’s vision and objectives for primary care. It sets out what Ontarians should expect when accessing primary care and requires the Minister of Health to report annually on progress toward those objectives. The Act is primarily a framework statute; it sets direction and accountability, rather than creating a fee schedule or detailed billing rules. This statutory framing is crucial because it signals how operational and financial details will be implemented: through policy, regulation, and program design that sit under the Act, not in the Act itself.
Bill 13 was introduced by the Minister of Health in May 2025 alongside broader primary-care investments and commitments to connect more residents to care teams. The government’s messaging around Bill 13 emphasized standardizing expectations of primary care access and outcomes while expanding capacity, including through teaching clinics and team-based models.
Public Funding for NP Primary Care by April 1, 2026
In January 2025, the federal Minister of Health issued a statement that, under the Canada Health Act, provinces and territories are expected to publicly fund “medically necessary physician-equivalent services” delivered by regulated professionals such as nurse practitioners, with changes taking effect April 1, 2026. The statement was explicit that PT (provincial/territorial) plans must adjust to cover these services and refrain from patient charges.
This federal policy interpretation does not write the OHIP fee schedule for Ontario. Instead, it sets a compliance deadline and a standard: by April 2026, Ontario’s plan must fund NP primary care services that are medically necessary. Bill 13 provides a provincial framework within which Ontario can implement such funding (e.g., via OHIP or another provincially approved payment mechanism), and the province remains responsible for the mechanics (enrollment, codes, rates, documentation rules, and audit frameworks).
What NPs Can and Cannot Bill Under OHIP (Pre-2026)
Under current practice (pre-April 2026), Ontario NPs typically cannot bill OHIP on a fee-for-service basis for assessments, diagnosis, and treatment, even though they may hold OHIP provider numbers for administrative purposes such as initiating referrals or ordering tests. This is reflected in NP and regulator guidance that distinguishes possession of a billing number from the ability to submit fee-for-service claims. Physicians can bill OHIP for consultations arising from NP referrals; the NP’s provider number appears on the referral requisition.
The College of Nurses of Ontario (CNO) clarifies that NPs are authorized to diagnose, order and interpret diagnostic tests, and prescribe medications, among other controlled acts. Those authorities already support broad NP practice in Ontario; what changes in April 2026 is the public funding pathway for primary-care services, not the underlying clinical scope.
Unknowns About Nurse Practitioner OHIP Billing Post-April 2026
As the landscape of nurse practitioner billing continues to evolve before and after the April 2026 timeline, a number of factors remain to be determined.
Enrollment and Provider Onboarding
The details of how NPs will enroll with OHIP (e.g., specific program codes, business numbers, group vs. solo enrollment) and what practice identifiers will be required are still being developed.
Compensation Model(s)
It remains to be seen whether Ontario will adopt fee-for-service codes, a blended model tied to patient panels and QI indicators, or integrate NPs into team-based funding envelopes with billable encounters.
Scope of Billable Services
A precise list of billable service codes for NP primary care (assessment types, counselling, chronic-disease management, preventive services, virtual care parameters, after-hours premiums, etc.) will need to be developed.
Claims Integrity and Audits
Documentation standards, record-keeping requirements, and audit risk management under the Health Insurance Act and related regulations have not yet been clarified.
Ontario historically implements these details through Schedules of Benefits, INFOBulletins, and program manuals under General Regulation 552 of the Health Insurance Act.
Practical Preparation for April 2026: Steps NPs Can Take Now
Even before the final OHIP program details are released, NPs can position their practices to be “billing-ready” by April 2026. The following areas are typically foundational in Ontario’s publicly funded system and are unlikely to change in principle, even if billing codes and rates are still forthcoming.
1. Professional Registration, Scope, and Delegation Policies
Ensure that your CNO registration (Extended Class) and any scope-expansion updates are current. Review the latest CNO practice standards and ensure that your clinic policies reflect diagnostic authority, prescribing, ordering, and intra-professional collaboration. If your model involves delegation or shared care with physicians or other providers, update delegation protocols and medical directives accordingly.
2. OHIP Administrative Readiness
If you do not already have an OHIP provider number, apply in advance to link it to your legal name and practice location(s). Historically, provider numbers have been required for ordering and referrals and will be central to any claims submission model. Ensure your business’s legal structure and banking are aligned to receive remittances.
3. Business Structure and Contracting
Decide whether to practice as a sole proprietor, a professional corporation (if permitted), or through a group practice/inter-professional clinic. This choice affects liability, tax treatment, contracting, and how you enter into any OHIP enrollment agreements or clinic association agreements. For team-based models (e.g., family health teams or community-based clinics), examine how NP services will integrate with existing funding streams and whether your compensation will be a hybrid of program funding and billable encounters.
4. EMR, Data Quality, and Claims Support
Select or optimize an Electronic Medical Records (EMR) system capable of capturing structured data aligned to OHIP billing requirements. Most Ontario fee schedules require precise diagnostic/assessment coding, encounter documentation, and time stamps to support claims and withstand retrospective review. Build templates that reflect preventive care, chronic-disease management, and virtual care documentation, anticipating the likely billing constructs Ontario will publish.
5. Privacy, Security, and PHIPA Compliance
As Ontario transitions NPs into publicly funded billing, Personal Health Information Protection Act (PHIPA) obligations remain paramount. Appoint a privacy officer, maintain up-to-date privacy policies, and conduct periodic privacy impact assessments, especially if your practice uses virtual platforms or third-party apps. Ensure consent management, secure messaging, access controls, audit logs, and breach response protocols are documented and operational. Bill 13 references “personal health information” by adopting PHIPA’s definition, reinforcing that the primary-care framework expects robust privacy compliance.
6. Quality Improvement and Reporting
Bill 13 requires the Minister to report annually on progress toward primary-care objectives. It is reasonable to expect that performance reporting and quality indicators will become more visible across care models. Prepare your practice to capture standard QI metrics (e.g., attachment, access, continuity, preventive care completion rates, and chronic-disease outcomes) so you can benchmark performance and, if needed, meet participation requirements for any blended-funding or incentive programs.
7. Collaborative Pathways and Referrals
Physicians already bill OHIP for consultations resulting from NP referrals, and this integrated referral environment will continue after April 2026. Strengthen your specialist referral pathways, ensure your requisitions carry all required identifiers, and maintain timely consultation feedback loops, a standard expectation in Ontario’s Schedule of Benefits.
Willis Business Law: Helping Ontario Nurse Practitioners Prepare for 2026
As a trusted business law firm based in Windsor-Essex County, Willis Business Law helps nurse practitioners and clinic owners structure and launch practices ready for public funding. Our associate lawyer, Meghan Davidson, advises on business formation (including professional corporations where applicable) and vendor contracts for Electronic Medical Records providers and billing services. We also prepare compliance frameworks tailored to Ontario’s regulatory environment: PHIPA privacy programs and privacy-officer mandates; consent and confidentiality policies; documentation standards aligned to anticipated OHIP requirements; and risk-management protocols for audits and reviews under the Health Insurance Act.
As Ontario finalizes the operational details for NP OHIP billing ahead of April 2026, we can help you map timelines, review Ministry materials, adapt your clinical and billing workflows, and ensure your practice launches on a compliant, sustainable footing. To book a consultation with our team, please contact us online or call (519) 945-5470.
