OHIP Coverage: Is it covered? (2024)

Canada offers its residents universal healthcare but depending on what province you live in, your coverage can vary greatly. Some provinces offer broader coverage for free of charge while others offer only medically necessary treatments.

For instance, in Ontario, there are some significant gaps in OHIP coverage, and you will need to pay some costs out of your pocket. These can be quite high in a province like Ontario. That's why you need supplemental private health insurance to bridge the gaps in coverage. But for that, you need to know what OHIP exactly covers.

In this comprehensive guide, we take you through Ontario's provincial OHIP coverage, what it doesn't cover, how you can apply for the OHIP if you haven't already, and more.

What is OHIP?

If you are a resident of Ontario, you may be eligible for the government-run health plan known as the Ontario Health Insurance Plan. This is commonly referred to just as OHIP. OHIP is paid through and funded by your taxes.

OHIP pays for a variety of healthcare services; however, these services must be deemed medically necessary. Services include visits to your family doctor and specialists. Additionally, most basic and emergency health care services are covered by OHIP.

What is OHIP coverage?

The coverage provided by OHIP includes a variety of medical services such as doctor visits, hospital stays, diagnostic tests, surgeries, emergency care, and some specialist appointments. However, it's important to note that while OHIP covers many essential services, there are also limitations and exclusions in the OHIP coverage list.

Understanding OHIP coverage is crucial for residents to make informed healthcare decisions and, if necessary, consider private supplemental health insurance to address any gaps in coverage that may arise.

What does OHIP cover?

The OHIP coverage list primarily includes medically necessary treatment. The tool at the top of this page will also let you check if something is covered and for how much. We have compiled a table to break down exactly what is covered under OHIP.

OHIP Coverage List	What is covered by OHIP
Doctors	Whether you visit your doctor, or if you see one in a walk-in clinic, OHIP covers the full cost of your services – as long as they’re medically necessary.
Hospital visits and stays	If you need to go to the hospital, OHIP covers: doctor and nursing services diagnostic testing (blood work, x-rays) medications while inpatient (once a patient is discharged, prescribed medications are not covered) accommodation and meals if you have to stay Note: if you want a private or semi-private room, you or your private insurance will have to pay some or all of those hospital fees
Dental surgery in hospital	Some dental surgeries need to be performed in a hospital because they are complex and/or you have another medical condition that needs monitoring during the procedure. OHIP covers in-hospital dental surgeries such as: Fracture repair Tumor removal Reconstructive surgeries Medically necessary tooth removal (prior approval by OHIP is required)
Optometry (eye-health services)	OHIP covers the cost of one major eye exam (for vision and general eye health) every 12 months, plus any minor assessments you need, but only if you are: 19 years and younger 65 years and older If you are 20 to 64 years old, and you have a qualifying medical condition affecting your eyes that requires regular monitoring, OHIP will cover a major eye exam for you once every 12 months and any follow-up appointments related to the condition. Covered conditions are: diabetes mellitus glaucoma cataract retinal disease amblyopia visual field defects corneal disease OHIP may also cover a major eye exam if it has been requested for a specific reason by your doctor (they will need to give you a referral form).
Podiatry (foot-health services)	It covers between $7 and 16 per visit to a registered podiatrist (up to $135 per patient per year). OHIP podiatry coverage also includes $30 for x-rays. You will need to pay for the remainder of the cost of each visit.
Ambulance services	If you need an ambulance for a medical emergency, OHIP covers part or all the costs.
Travel for northern-Ontario residents	If you have to travel long distances for specialized medical care, OHIP may help pay for your travel and accommodation through the Northern Health Travel Grant.
Abortion services	OHIP covers the cost of: surgical abortions that take place in a hospital or clinic Mifegymiso (a pill that induces abortion in early pregnancy) if you have a prescription from your doctor

What is OHIP coverage out of province?

When Ontario residents travel outside of the province within Canada, their OHIP coverage extends to emergency medical services that are considered medically necessary. This means that if you require urgent medical attention, such as visiting a hospital or seeing a physician, OHIP will cover those essential services.

For instance, ambulance services, prescription medications, and non-urgent medical treatments may not be fully covered by OHIP when you're outside of Ontario. To address these potential gaps and ensure comprehensive coverage during your travels, it's highly recommended to acquire additional travel insurance to bridge the gaps in out-of-province OHIP coverage.

Travel insurance can provide financial protection against unexpected medical costs that might not fall within the scope of OHIP's coverage while you're out of the province. This way, you can travel knowing that you're adequately protected in case of any unforeseen medical situations.

What is not covered by OHIP?

While OHIP covers many basic medical services, there are also services not covered that could leave you with a costly bill. Services excluded under OHIP are

• Prescription drugs provided in non-hospital settings (e.g. antibiotics prescribed by your family doctor)
• Dental services provided in a dentist’s office
• Eyeglasses, contact lenses
• Laser eye surgery cost
• Cosmetic surgery

What is the OHIP coverage list or Schedule of Benefits?

For a complete and detailed list of covered services, you can refer to the official OHIP Schedule of Benefits, published by Ontario’s Ministry of Health. This document not only outlines the types of services covered but also includes essential information such as the conditions under which each service is covered, specific limitations, and billing codes for healthcare providers.

Additionally, the OHIP coverage list document provides the set fees for each service, offering insight into pricing and reimbursement rates. This comprehensive guide is a valuable resource for understanding OHIP's scope and limitations in healthcare coverage.

Familiarizing yourself with this schedule means you’ll be more prepared, whether it’s for a routine doctor’s visit, a diagnostic test, or specialized treatment. Here are the official OHIP coverage lists for 2024 for each health category.

What is included in OHIP dental coverage?

OHIP's dental coverage is limited primarily to dental surgeries that are considered medically necessary and must be performed in a hospital setting due to their complexity or the need for medical monitoring during the procedure. Some examples of dental surgeries covered by OHIP include:

1. Fracture Repair: Surgical treatment of facial bone fractures that require intervention in a hospital setting.
2. Tumor Removal: Surgical removal of oral tumors or growths that necessitate hospital-based procedures.
3. Reconstructive Surgeries: Dental or facial reconstructive surgeries that are required due to traumatic injuries or congenital conditions.
4. Medically Necessary Tooth Removal: Extraction of a tooth deemed medically necessary and approved by OHIP.

It's important to emphasise that routine dental care, such as cleanings, fillings, extractions not deemed medically necessary, and other general dental procedures, are not covered by OHIP. Even wisdom teeth removal costs aren't covered. Dental services provided in a dentist's office, including regular check-ups and preventive care, fall outside the scope of OHIP dental coverage.

How much is dental care without OHIP dental coverage?

Below are estimated costs for common dental services that are typically not covered by public health plans like OHIP, Medical Services Plan (in BC), and Quebec (RAMQ).

Dental Service	Ontario Estimate	British Columbia Estimate	Quebec Estimate
Regular Dental Check-up	$100 - $150	$100 - $150	$100 - $150
Dental Filling (Composite)	$150 - $250	$150 - $250	$150 - $250
Dental Filling (Amalgam)	$100 - $200	$100 - $200	$100 - $200
Tooth Extraction	$150 - $300	$150 - $300	$150 - $300

As you can see, you will be shelling out quite a bit from your pocket for these essential services not covered by your provincial healthcare. Therefore, we highly recommend taking out a private health and dental insurance plan for extra coverage to protect you against large medical bills and assure your ability to pay for treatments, prescription drugs and dental care that does not fall under the OHIP dental coverage.

You can compare the best health insurance in Ontario to find a plan that works for you best. You could simply use our comparator below and get health insurance quotes from the best providers in Canada to suit your unique needs and budget.

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What is OHIP coverage for seniors?

OHIP coverage for seniors in Ontario includes a range of medically-necessary healthcare services. Here are some key points about OHIP coverage for seniors:

1. Medical Services: OHIP covers doctor visits, specialist consultations, and diagnostic tests for seniors.
2. Hospital Stays: It includes doctor/nurse services, tests, and meals during hospitalization. Private rooms might require extra payment.
3. Eye Exams: Seniors 65+ get one annual major eye exam covered; some conditions extend coverage for ages 20-64.
4. Travel Assistance: The Northern Health Travel Grant helps cover travel costs for specialized care.
5. Physiotherapy: Covered after an overnight hospital stay within the last year.
6. Medically Necessary Dental: Some dental surgeries in a hospital setting are covered.
7. Exclusions: OHIP doesn't cover outpatient drugs, routine dental care, eyeglasses, or elective procedures.
8. Supplemental Insurance: Seniors often opt for private insurance to cover gaps like dental, prescriptions, and more.

What is OHIP dental coverage for seniors?

OHIP's dental coverage for seniors in Ontario is limited primarily to medically-necessary dental services that must be performed in a hospital setting due to their complexity or the need for medical supervision during the procedure. OHIP dental coverage for seniors includes dental surgeries that are essential for medical reasons. Examples of such procedures include fracture repairs, tumor removals, and reconstructive surgeries that affect oral health.

Routine dental care, such as regular check-ups, cleanings, fillings, and other general dental procedures, are generally not under the OHIP dental coverage for seniors. Additionally, costs associated with prescription lenses, eyeglasses, cosmetic dental procedures, and dental services provided in a dentist's office are typically not covered.

What is OHIP drug coverage?

The OHIP primarily covers medically-necessary healthcare services, but it generally does not cover prescription drug costs for individuals in the province. However, there are certain exceptions and programs related to the OHIP drug coverage in Ontario:

1. Ontario Drug Benefit (ODB) Program: The ODB program provides prescription drug coverage to eligible Ontario residents who are 65 years of age and older, as well as those receiving social assistance. It assists with the costs of prescription medications for various health conditions.
2. Trillium Drug Program: This program helps individuals and families with high prescription drug costs in relation to their income. It provides coverage for prescription medications based on the individual's ability to pay.
3. Limited Drug Coverage: OHIP drug coverage includes certain medications administered in hospitals or medical settings, such as chemotherapy drugs and medications provided during hospital stays.
4. Drug Programs for Specific Conditions: Some medical conditions have associated drug programs that provide coverage for medications used to treat those conditions. These programs can vary based on the medical condition and eligibility criteria.
5. Private Prescription Drug Plans: Many individuals in Ontario opt for private prescription drug insurance plans to cover the costs of medications not covered by OHIP or the government programs mentioned above.

Does OHIP cover physiotherapy?

Physiotherapy services received at government-funded physiotherapy clinics are covered through OHIP. A physiotherapist will provide assessment and treatment services, including rehabilitation following an injury or hospital stay.

However, not everyone individual is eligible for physiotherapy coverage under OHIP.

With a valid OHIP card you can receive government-funded physiotherapy if you are:

• 19 years or under
• 65 years or older
• any age after an overnight hospital stay (within the last 12 months) for a condition requiring physiotherapy
• a recipient of the Ontario Works or the Ontario Disability Support Program (any age, OHIP card not required)

A private health insurance plan can cover physiotherapy for any age. Having good health insurance coverage is important. You never know when an injury may occur requiring physiotherapy.

What other services does OHIP cover?

How is OHIP medication coverage?

OHIP medication coverage does not include outpatient prescription medications except for specific instances such as medications administered during hospital stays. However, Ontario residents can access drug coverage through the Ontario Drug Benefit (ODB) program, which provides assistance for eligible seniors (65+) and individuals receiving social assistance.

Additionally, the Trillium Drug Program offers coverage based on income for those with high prescription drug costs. Private prescription drug plans are commonly chosen to address medication expenses not included in OHIP medication coverage or government programs, offering more comprehensive coverage for various medical needs.

Does OHIP cover eye exams and prescription lenses?

Annual eye exams are fully covered by OHIP for children (19 or younger) and for seniors (65 or older). If you are an adult between the ages of 20 and 64 years old, routine eye exams are not covered by OHIP and will need to be paid out of pocket or through private insurance.

Note that adults with specific eye conditions requiring regular monitoring are covered for an eye exam every 12 months. Additional follow-up appointments related to that condition are also covered. The OHIP coverage for eye exams is therefore quite inclusive.

Prescription lenses and contacts are not covered under OHIP prescription coverage and need to be purchased out of your pocket.

As you can see the list of healthcare needs not under OHIP coverage could lead to significant and often unaffordable costs. That's why a private health insurance plan is essential to make sure you have your health needs covered. You could start right away and use our comparator below to get personalized quotes from the best health and dental insurance in Canada.

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What is OHIP hearing aid coverage?

OHIP typically does not cover hearing aids costs for adults in Ontario. Exceptions include coverage for children under 18 with severe hearing loss. Adults might find assistance through Ontario's Assistive Devices Program (ADP) or private insurance plans that offer hearing aid coverage. Eligibility is determined based on specific criteria, and there might be financial support available for adults through this program.

Is therapy covered by OHIP?

Therapy is covered by OHIP if the treatment is done by a medical doctor. If your family doctor has training in psychotherapy, then treatment will likely be covered. However, most family doctors will refer you to a psychiatrist or specific mental health provider. If you work with a registered psychologist, registered social worker or registered psychotherapist, they may also be free if they work in government-funded hospitals or clinics.

If you do not have a family doctor or if they do not offer psychotherapy services, then it is unlikely OHIP will cover the service. This means that you will have to pay for any treatment you receive from a registered psychologist, registered social worker or registered psychotherapist who is not part of a government-funded hospital.

Is orthopedic covered by OHIP?

OHIP generally does not cover orthopedic supports like custom shoes, braces, or orthotics unless prescribed under specific in-hospital scenarios for medical necessity. You must pay out-of-pocket for outpatient orthopedic services, such as custom orthotics or shoes for daily use.

The cost of orthopedic devices can vary widely based on the type and customization needed. For example:

• Custom orthopedic shoes can range from $300 to $600 per pair.
• Custom orthotics often cost around $200 to $500.
• Braces or supports, depending on complexity, can vary from $100 to $800.

For those who rely on orthopedic support regularly, these costs add up quickly, making private health insurance a valuable supplement. Many private plans include orthopedic support, allowing for reimbursement of a significant portion of these costs.

If orthopedic coverage is a priority, explore your options with our free tool—compare Canada’s top health insurance plans and receive personalized quotes to find the best fit for your needs today.

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Am I eligible for OHIP coverage?

To be eligible for OHIP, you must meet all of the minimum qualifications listed below plus at least one of the additional requirements.

The minimum qualifications you must meet to qualify for OHIP coverage are:

• Be physically in Ontario for 153 days in any 12 months
• Be physically in Ontario for at least 153 days of the first 183 days immediately after you begin living in the province
• Make Ontario your primary residence

How do I apply for OHIP coverage?

If you fulfill the eligibility requirements for OHIP, you can apply in person by visiting a ServiceOntario Centre and bringing your completed Registration for Ontario Health Insurance Coverage form.

You will also be responsible for bringing along several types of original documentation (photocopies will not be accepted) to submit with your application. These include proof of

1. Identity
2. Citizenship or residency in Ontario
3. Your address in Ontario

See a complete OHIP accepted documents list right here.

Do I need an OHIP card?

Yes, you need an OHIP card to access public health services. Once you have applied to OHIP and been accepted, you will receive your Ontario health card. Your health card will prove that you are covered by OHIP. You will need to show it every time you see your doctor, go to the emergency room or undergo medical tests or surgery.

Read a complete guide on the OHIP card, its application, renewal, and more.

How does private health insurance work in Ontario?

Similar to car insurance or life insurance, with private insurance you pay a monthly premium to an insurance company in exchange for extra coverage for certain health care costs. Private health care covers a broader range of services and typically has high limits on the amount they will cover. Even if you qualify for OHIP, you can use private insurance to pay for some services that OHIP does not cover like cosmetic procedures from a dermatologist.

What does private health insurance in Ontario cover?

Private health insurance in Ontario can provide coverage for a range of healthcare services and treatments that are not covered by OHIP, the Ontario Health Insurance Plan.

1. Prescription Medications: Private insurance can cover the costs of prescription drugs not included under OHIP, including those purchased outside of hospitals.
2. Dental Care: Routine dental services, such as check-ups, cleanings, fillings, and orthodontics, are often covered. You can also get standalone dental insurance plans for comprehensive coverage.
3. Vision Care: Private insurance can cover expenses related to eye exams, prescription eyeglasses, contact lenses, and even laser eye surgery.
4. Paramedical Services: Coverage may extend to services like chiropractic care, physiotherapy, massage therapy, and other specialized therapies.
5. Specialist Visits: Private insurance can cover consultations and treatments provided by specialists that might not be fully covered by OHIP.
6. Medical Equipment: Coverage might include expenses for medical equipment like mobility aids, hearing aids, and assistive devices.
7. Travel Medical Insurance: Private insurance can offer protection against medical expenses incurred during travel outside of the province or country.
8. Alternative Medicine: Several plans cover treatments in alternative or complementary medicine, such as acupuncture or naturopathy.
9. Mental Health Services: Services such as counselling, therapy, and psychiatric care can be covered beyond what OHIP offers.
10. Hospital Upgrades: Private insurance might cover costs related to private or semi-private hospital rooms.
11. Critical Illness Coverage: Plans may offer lump-sum payments in the event of specific serious illnesses.

The specific coverage and benefits offered by private health insurance plans can vary widely. It's important to carefully review and understand the terms, exclusions, and limitations of any private insurance policy to ensure it aligns with your healthcare needs and preferences.

If you want coverage beyond the scope of what OHIP covers, private health insurance is right for you. For that, all you need to do is to use our comparator below to get personalized quotes from the best health insurance in Canada, and in just a few seconds.

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