OHIP: Summary of Benefits and Coverage Overview
The Ontario Health Insurance Plan commonly known as OHIP, is the government-run health insurance plan for the Canadian province of Ontario. OHIP is funded by a payroll deduction tax by residents who are gainfully employed, by businesses in the Province of Ontario, and by transfer payments from the Government of Canada.
Ontarians below 25 are covered for eligible prescription drugs listed with the Ontario Drug Benefit (ODB) or the Exceptional Access Drug formularies. This coverage became effective since January 1, 2018. Not all drugs are covered by the OHIP, you can get more information from the Ontario Government’s OHIP page.
You can opt for OHIP three months after settling in Ontario. You can also apply to OHIP if you just moved to Ontario or you are a returning expat. It is necessary you apply once you arrive at the province.
Services Available in OHIP
OHIP covers the following services fully or partially:
- • Doctor services deemed as a medical
- • Medically important hospital services such as meals, necessary drugs, procedures, and public wards but private and semi-private hospital rooms are not covered.
- • Eye examinations are covered for children below 20 and for seniors above 65. You will also be covered if you are suffering from a condition that requires a routine eye exam. For both cases, only one exam each year is covered.
- • OHIP covers the services of a registered podiatrist. It provides coverage from $7 to $16 for each visitation and a maximum of $135 for each person per annum. It also covers $30 for x-rays. Albeit surgery is not covered.
- • Ambulance services are covered only if it is used in transporting between hospitals or medical facilities or if the ambulance service is considered as a medical necessity. If the transportation does not commence from a medical facility, it will involve a $45 co-payment.
- • It may cover home care or long-term care depending on the applicant’s needs.
- • For women between 50 and 74 and those between 30 and 69 and are considered to be a high risk, mammograms may be covered through the Ontario Breast Screening Program (OBSP). The coverage may also apply if a physician refers you to a publicly funded Ontario clinic or hospital.
- • Dental surgery in a hospital is covered. This might include the removal of tumors, repair of fractures, reconstructive surgery and medically necessary tooth removal.
- • The services of midwives.
- • Surgical abortions carried out in a hospital facility or a clinic. If a doctor prescribes it, Mifegymiso may be covered.
- • Oral contraceptives and birth control pills are also covered by OHIP+ for residents below 25. Residents 25 and above and considered to income may also be covered if they qualify for a specialty drug program.
Bills may apply if you do not have a valid health card or if you miss an appointment with a physician.
Northern Health Travel Grant
If you live in northern Ontario and may need to travel a long distance for a special medical care, you can leverage the Northern Health Travel Grant. This grant is designed to offset the travel cost involved.
Residents living in these areas can take advantage of this coverage: Algoma, Kenora, Sudbury, Cochrane, Nipissing, Manitoulin, Parry Sound, Rainy River, Timiskaming, and Thunder Bay.
Services Not Covered by OHIP
The following Services are not covered by OHIP:
- • Regular eye exams for residents between 20 and 65.
- • Ambulance services that are not considered as medical necessities.
- • Laser eye surgery, glasses, and contact lenses.
- • Physiotherapy except you meet one of these conditions: You are under 20 or above 65, you are discharged as an inpatient from a hospital after a night stay and require physiotherapy to recover from the condition, or you are referred by a nurse or physician and are a client of the Ontario Disability Support program or Ontario Works.
- • The services of paramedicals such as chiropractors, massage therapist, osteopaths, acupuncturists, naturopaths, etc.
- • Dental services carried out in a dental office.
- • Emergency medical treatments considered necessary and carried out outside Canada are only covered on a limited It is advised that you have a travel insurance coverage if you are traveling outside Canada. Further, the plan does not cover ambulance transportation cost outside the province.
- • Cosmetic surgeries.
- • Private and semi private hospital rooms.
- • As of January 1, 2018, prescription drugs for people above 25 are not covered anymore. However, you may get some assistance depending on your condition.
- • Contraceptives and birth control pills are not covered except for people below 25 or those that qualify for a specialty drug program such as residents from a low income family.
Benefits of Ontario Drugs
The Ontario Health Insurance plan does not provide coverage for prescription drugs but people who require assistance in paying prescription drugs can also get the needed help.
The Ontario Drug Benefit offers assistance to Ontarians who have a valid Ontario health card and are:
- • Are senior citizens aged 65 and
- • Residents of Ontario who live in long-term care homes and special care homes.
- • Ontarians on social assistance such as Ontario Works and/or Ontario Disability Support program.
- • Ontarians receiving professional home care services.
If you do not qualify for the ODB program, you can opt for the Trillum Drug Plan (TDP). This plan is for Ontarians whose prescription costs are high when compared to their income and who do not have private insurance coverage or have very little private insurance coverage.