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What Exactly Are the Services Covered by OHIP?

on 17 Jul, 2019

Ontario spends more than $53 billion on its healthcare system every year. People living in Ontario fund the Ontario Health Insurance Plan through their taxes.

For a $53 billion price tag, you’re wondering what, exactly, this plan covers. While there are quite a few services covered by OHIP, there are also many that aren’t. Trying to sort out what is and isn’t covered is sometimes a bit tricky.

We sorted through the information so you don’t have to. If you’re asking, “What does OHIP cover?” wonder no more.

The Basic Services Covered by OHIP

OHIP provides essential medical coverage for all Ontarians. To this end, the plan covers quite a few medical expenses and services.

The largest part of Ontario’s healthcare budget is devoted to hospitals. OHIP provides coverage for most hospital services. This includes:

  • Doctor and nursing services
  • Tests such as X-rays and blood tests
  • Medications for the duration of your stay
  • Some out-patient medications
  • Hospital accommodations
  • Hospital meals

If you need to take an ambulance to the hospital for an emergency, OHIP covers the cost.

OHIP will also cover costs for dental surgery that takes place in a hospital. This could include surgery for fixing a fracture or removing a tumor.

Coverage for Most Doctors

When you visit a doctor in Ontario, your visit is usually covered by OHIP. This includes most specialists, as well as your family doctor.

OHIP provides limited coverage for the services offered by some medical professionals. One example is optometry. People under age 19 and those over 65 can get a free eye exam once a year.

People with diabetes or glaucoma may need to see an eye specialist more often. They can qualify for coverage from OHIP. In some cases, OHIP will cover major eye exams if they’re requested by a doctor for a specific reason.

Ontarians who use Ontario Works or the Ontario Disability Support Program may qualify for more benefits.

Partial Coverage of Some Services

OHIP may offer some coverage for services offered by some medical professionals. A good example is podiatry, which is care for the feet.

Some services offered by podiatrists are also eligible for partial OHIP coverage. You could receive up to $135 per year for visiting a podiatrist.

Surgery performed by a podiatrist isn’t covered by OHIP.

Some services provided by a family doctor or specialist may not be fully covered.

Services for Women

OHIP offers coverage for many services associated with pregnancy and childbirth. The services of an obstetrician and a midwife alike are covered.

Abortion services performed in a hospital or clinic are also covered under OHIP. Some prescription medications for this purpose are also covered.

You may be eligible for coverage of some forms of birth control if you are under 25 years of age. The OHIP+ program provides this coverage. Since birth control pills are prescription medications, they may be covered.

Breast cancer screening in the form of mammograms is also covered under OHIP. If you are between the ages of 50 and 74, you don’t need a referral. If you’re under the age of 50, your doctor can refer you if they think you’re at risk.

The Ontario Drug Benefit Program

Prescription medications aren’t usually covered for people living in Ontario. There are a few exceptions to this rule.

People who are 65 or older are enrolled in the Ontario Drug Benefit program. The ODB lists 4,400 drugs that the province will cover.

Seniors pay a $100 deductible annually. High-income seniors will then pay $6.11, while low-income seniors pay $2. This is the province’s co-payment plan.

Young Ontarians may also qualify under the ODB. If you’re under 25 and don’t have private health insurance, OHIP pays for prescriptions.

People who are receiving benefits from Ontario Works or ODSP are also eligible for the ODP. People living in long-term care homes and those who receive home care also qualify.

Ontarians who face high drug costs can apply to the Trillium Drug Program.

Travel Grants for Remote Communities

If you live in Northern Ontario, you may qualify for a travel grant offered by OHIP. Since communities in Northern Ontario are remote, they’re often underserved. It can be challenging for residents to travel to medical appointments.

The Northern Health Travel Grant could help you pay for travel and accommodations. This grant is available if you need to travel long distances to get medical services. It’s available to residents of Parry Sound, Rainy River, Sudbury, and several other areas.

What OHIP Doesn’t Cover

The list of what OHIP does cover is far from exhaustive. In fact, you might be surprised to learn the list of what OHIP doesn’t cover is actually longer than what it does cover.

We already mentioned that OHIP doesn’t cover prescription medications for most Ontarians. If you’re over the age of 25, under the age of 65, or have private insurance, you likely won’t receive help from the province.

Even if you do qualify for the ODB, the list of covered medications is limited.

Coverage for vision care is also limited. As noted, people under the age of 19 and over the age of 65 can see an optometrist for free once a year. Anyone else will need to pay for their eye exams.

Even if you do qualify for free eye exams, you’ll likely still need to pay for glasses and contact lenses. Laser surgery is also not covered. Corrective surgery for some conditions, such as cataracts, is covered.

Dental care is another major gap in OHIP. While the plan covers some surgery, routine dental care is not covered. You’ll pay out of pocket for regular cleanings, check-ups, and even imaging.

You’ll also pay for many procedures, such as tooth extractions and fillings for cavities. Braces, dentures, and other devices are not covered.

Help for Medical Devices

Another major gap in OHIP coverage is assistive devices. OHIP doesn’t provide much if any, coverage for medical devices that can improve your quality of life.

The province offers an Assistance for Medical Devices program. The program helps some Ontarians cover the cost of personalized medical devices.

This program only assists people with physical disabilities.

Forms and Notes

Your doctor may provide forms, such as claims for Employment Insurance if you’re on leave. Your employer may also ask you to supply a doctor’s note if you’re ill. An insurance company can ask you for a prescription for massage or physiotherapy.

OHIP doesn’t cover the cost of this paperwork. You’ll pay out of pocket for most notes and forms.

Determining Medical Necessity

OHIP covers “medically necessary” services and expenses for Ontarians.

If a service isn’t considered necessary, it won’t be covered by OHIP. Cosmetic surgery, for example, isn’t covered. It’s not medically necessary.

This is why OHIP will cover some services provided by a doctor and not others. A good example is wart removal. In some cases, this may be deemed medically necessary, and OHIP will cover it.

Some services are “supplementary” health services. These include:

  • Massage therapy
  • Physiotherapy
  • Chiropractic services
  • Acupuncture

There’s a debate in the medical community about the value of some of these services. They’re not considered medically necessary, even if they improve patient outcomes.

This is also why OHIP will pay for ambulance services in medical emergencies, but not in a non-emergency.

OHIP also doesn’t pay for semi-private or private hospital rooms. Those are “upgrades” that are medically unnecessary. If you want them, you’ll have to pay for them.

What to Do If OHIP Won’t Pay

When you realize how many services and medical expenses OHIP doesn’t pay for, you may be worried.

What will you do if you need costly prescription medications? What will happen if you’re in an accident and need physiotherapy to regain full use of your hands?

Supplemental health insurance is a good idea for every Ontarian. You have a solid foundation with the provincial plan. There are still many medical costs you could end up paying out of pocket for.

A good plan will help you receive coverage for what OHIP doesn’t cover, such as:

  • Prescription medication
  • Dental services
  • Vision care
  • Services like physiotherapy and massage therapy

Whether you’re a senior, a young Ontarian, or a new parent, supplemental insurance just makes sense.

Understand Your OHIP Coverage

This guide should help you understand most of the services covered by OHIP and which ones aren’t. If you have questions about specific services or expenses, don’t be afraid to ask.

If you want to start filling in some of the gaps in your OHIP coverage, it’s time to look for supplemental health insurance. You can start comparing quotes right now.

The right health insurance will help you protect your health and your future.

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