Ontario is Canada’s most populous province. The fastest growing segment of the population is those aged 65 and over. In fact, by 2041, it’s predicted seniors will make up one quarter of Ontario’s population.
In 2019, that would have translated to more than 4.5 million people. Ontario seniors made up 16% of the population. In the most recent statistics collected in 2021, this translates to more than 7 million people. Currently, Ontario seniors make up 18.5% of the population.
As a group, older Ontarians have unique needs that future governments must address. Some of those questions revolve around residential care, such as nursing homes. Day programs and financial support are also concerns.
Older people are also more likely to encounter health issues. The growing senior population poses some challenges for Ontario’s healthcare system.
Like all Ontarians, seniors in Ontario have coverage under the provincial plan. It's known as OHIP, which is short for Ontario Health Insurance Plan.
Many people wonder what OHIP coverage after age 65 looks like. Many seniors have a fixed income and no employer-sponsored benefits.
Our guide reviews OHIP coverage for those over 65. We’ll also look at some of the recent changes in this area.
Who Has OHIP Coverage?
Almost every person who lives in Ontario is entitled to health insurance under OHIP. If you live in Ontario and pay taxes, you likely have healthcare coverage.
To access your OHIP health benefits, you’ll need a health card. You can get one from any Service Ontario location. You can also apply for one online.
Ontario used to issue “lifetime” health cards, which never expired. Now health cards include pictures, which means you must update them every so often. Be sure to replace your card so you always have coverage.
What OHIP Covers
Like other provinces in Canada, Ontario provides coverage for many basic medical expenses. OHIP includes coverage for:
- Hospital stays
- Visits to the doctor
- Appointments with most specialists
- Podiatry (foot-health services)
- Eligible dental surgery in hospital
- Eligible optometry (eye-health services)
- Medical or surgical abortions
- Travel for health services if you live in Northern Ontario
- Some medical items
For most Ontarians, OHIP doesn’t cover many different services. You may pay out of pocket for:
- Vision care, including prescription glasses and visits to the optometrist
- Dental care, excepting some surgeries
- Prescription medications
- Cosmetic surgery
When it comes to groups like children and seniors, though, coverage changes a little bit.
OHIP Coverage After Age 65
Ontarians continue to be covered by the public healthcare system even after they turn 65. You might lose your employer-sponsored benefits when you retire from your job. The province’s insurance stays intact.
In fact, OHIP gets a little bit better for seniors. OHIP senior benefits include:
- Coverage for visits to the optometrist every two years
- Coverage for most prescription medications
- Coverage for physiotherapy
- Coverage for home care services
The reasoning on providing expanded benefits to seniors is simple. As a group, senior Ontarians tend to have fixed incomes. When they retire, their income may decrease as they draw on social assistance.
They may also lose employer-sponsored benefits. Their income may mean they can’t afford supplementary health insurance.
They also tend to have higher healthcare costs. As people age, they have a higher risk of developing a chronic illness. Many seniors live with diabetes, arthritis, and other health conditions.
Older people also have a higher likelihood of developing an illness such as cancer.
Due to these facts, senior citizens may struggle to pay for necessary medications. Expanded senior OHIP coverage ensures more seniors can access the healthcare they need.
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Changes to OHIP Coverage
In the past two years, the Government of Ontario has introduced many changes to OHIP. First, the Liberal government introduced some measures to expand the program. The highlight of OHIP+ was prescription medication coverage for people under 25.
OHIP+ also expanded senior OHIP coverage. Beginning in August 2019, the province would cover all prescriptions for senior citizens. Before, the government had offered seniors a co-pay arrangement.
Under the co-pay, seniors would pay a $100 deductible then cover most of their prescription medications. The level of coverage depended on their income.
Seniors with low incomes would pay only a $2 co-payment. Seniors with higher incomes paid $6.11 per prescription.
Some pharmacies didn’t charge the co-payment. Low-income seniors paid nothing and others paid $4.11. This arrangement didn't cover all prescription medications either.
Senior advocacy organizations announced their support of changes. Even though only some medications were covered, lower fees would help many seniors.
In September 2018, the new Conservative government rolled back some of these changes. They announced that OHIP+ wouldn't cover children and youth who had private benefits. The private insurer would need to cover medications instead.
The province didn’t announce that it was canceling OHIP+ for seniors. It stated as much in its economic statement in fall 2018. OHIP+ would have removed the deductible and co-payments for all seniors.
For now, it seems like senior OHIP benefits are status quo for Ontarians.
Prescriptions OHIP Doesn’t Cover
Seniors’ drug coverage under OHIP is guided by the Ontario Drug Benefit program. At the time this article was published, the ODB included a database of 4,400 medications the province will pay for. As of 2022, there are now 5000 medications on that list.
This means some seniors won’t be able to access coverage for some of their prescriptions. If your medication isn’t in the ODB, the province likely won’t cover it.
You can apply to the Trillium Drug Plan if your medication isn’t covered by the ODP. The Trillium plan helps Ontarians who have high medication costs. It also assists in cases where medications are necessary, but uncovered by ODB.
In most instances, the province prefers generic medications over name-brand medications. If you need the name-brand, make sure your doctor notes this on the prescription. Otherwise, the province may not extend coverage.
What OHIP Won’t Pay
Around two-thirds of Canadians have supplemental health insurance through a private insurer. Often, an employer provides health insurance as part of an employee benefits package.
Very few employers offer benefits plans that follow employees into retirement. For most Canadians, the reality is that they lose private benefits when they turn 65 or when they retire.
While you’ll still have some coverage under OHIP, it’s clear it may not be enough. OHIP coverage does expand for senior citizens, but some people have to make tough choices. For some, they may have to choose between buying food or paying for medical services.
Medical expenses can still put the squeeze on “high income” seniors. This is especially true if you need uncovered medical services.
Medication for rheumatoid arthritis may be covered but you may not have coverage for massage, physiotherapy, or other supportive health services.
Using physiotherapy as an example, OHIP will cover sessions for seniors to address a new injury, fall, surgery, or accident. It will not cover sessions for seniors who simply want to maintain an existing level of mobility or range of motion, need specialized services, want long-term rehabilitation, or receive other physiotherapy services funded through other government funded healthcare programs, the WSIB, or through auto-insurance.
Seniors with complex medical conditions are eligible for in-home care services. You’ll have to call your Home and Community Care Support Services to apply. First, a case manager will determine if you are eligible, then they will assess the services you require and the duration you’ll need them for.
Some seniors also rely on in-home care services or care supplied in a nursing home. The provincial plan provides little in the way of financial help for these services if you're not eligible. If you need oxygen, for example, you’ll need to pay out of pocket.
As you can see, there are many medical items and services OHIP won’t pay for.
Another shortcoming of the OHIP program is that it provides only for one person. When you turn 65, you’ll receive expanded coverage. This includes prescription medications and vision care, physiotherapy and in-home care services.
Your dependents, such as your children or your spouse, won’t. If they were enrolled in your private benefits plan, they will lose their coverage altogether.
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What You Can do
OHIP provides basic coverage, which is better than nothing. For many Ontarians, OHIP senior coverage just isn’t enough.
Before you turn 65, you should invest in supplemental healthcare insurance for yourself. This can help you deal with the loss of private benefits through an employer. It can also ensure you have the right coverage for your dependents when you receive expanded senior OHIP benefits.
Why should you buy supplemental insurance before you turn 65? Remember that insurance companies determine premiums by assessing risk. When you turn 65, there’s a greater likelihood you’ll need to use this plan.
Your premiums will increase as a result. If you buy the plan before, you can lock in at a better rate than you might be offered otherwise.
You should look for a plan that offers good coverage for a reasonable price. Think about what your income is likely to look like after you retire as well. You want a plan that will be affordable for you on your retirement income.
A supplemental insurance plan may seem expensive up-front. In the long run, the right supplemental insurance can save you much more.
Prepare for the Future of OHIP
As the last few years have proven, OHIP coverage after age 65 is likely to be an area of change in the future. As more Ontarians reach retirement age, the province must rethink how it delivers healthcare for them.
What’s clear is that there are gaps in the system and they’re unlikely to be closed up any time soon. Having the right supplemental health insurance can help you weather any changes to the OHIP+ program.
If you’re thinking about exploring other insurance plans, you’re in the right place. Check out our blog for tips on how to find the right plan for you.
Or if you have additional questions and would like to speak to an insurance professional, we are here for you. Insurdinary has proudly assisted millions of Canadians find the right health insurance coverage for their unique and individual needs. Contact us today. We look forward to working with you.