Your Comprehensive Guide to OHIP Coverage for Seniors

Posted on April 29, 2019

Are you a resident of Ontario and about to retire?

You might be wondering what kind of health care awaits you after you lose access to any employer-funded private insurance programs.

As you likely already know, all residents of Ontario can participate in the Ontario Health Insurance Plan (OHIP).

The list of items covered by OHIP is long and fortunately covers the most essential services. However, Canadians over 65 will also spend an average of $5,391 per year on out-of-pocket medical expenses.

And given the 54 percent rise in health care costs between 2004 and 2014, those who are 65 or soon to be 65 can expect their personal health costs to grow, too.

OHIP covers essential medical and emergency services and either part or all of the costs. But what else does you little green OHIP card offer you? Keep reading to learn more about OHIP coverage for seniors.

Who Qualifies for OHIP?

You qualify for OHIP if you live in Ontario. However, there is a residency test: you must either be in the province for at least 153 days per year or be there for at least the 153 of the first 183 days after you moved to Ontario.

You also need to be either a:

  • A Canadian citizen, or
  • An indigenous person, or
  • Permanent resident of Canada, or
  • Permanent residence applicant, or
  • Convention refugee or protected person

If you were born in Ontario or have already lived there for several years, your coverage begins right away. Your coverage also beings when you move from another province or territory and into an Ontario long-term care home.

What Services Does OHIP Cover?

All OHIP enrollees have access to the following services:

  • GP visits
  • Nurse practitioner visits
  • Hospital services and stays
  • In-hospital dental surgery
  • Podiatry services
  • Optometry services
  • Ambulance services
  • Physiotherapy services

However, OHIP only covers part of the cost of some of these services.

Let's dive in to see what expenses seniors are responsible for.

GP Visits

If you need to go to the GP, OHIP covers your fee.

OHIP won't cover your fee if the visit isn't medically necessary.

Hospital Services

If you need to visit the hospital to access services or if you are admitted to the hospital, then OHIP covers you.

Specifically, OHIP covers all your:

  • Doctor services
  • Nursing services
  • Diagnostic testing services
  • Medications for in-patients
  • Accommodation and meals for hospital stays

OHIP only covers some out-patient medications. Additionally, OHIP does not include private or semi-private rooms.

In-Hosptial Dental Surgery

Dental health plays a crucial role in physical health, and you may find that you need dental work as part of your treatment.

Additionally, you may be in the hospital as a result of a dental issue. Generally, OHIP covers fracture repairs, reconstructive surgeries, and tumor removal.

In some cases, such as when it's required for other treatment, OHIP covers necessary tooth removal. However, it requires approval by OHIP.

Podiatry Services

OHIP covers visits to a registered podiatrist. It includes $7-16 of a visit. You also have an annual cap of $135 plus $30 for necessary x-rays.

You are not covered for podiatry surgeries even as a senior.

Optometry Services

If you are age 65 or older, then OHIP covers one major eye exam each year. It may also include minor assessments when the ophthalmologist deems it necessary.

Ambulance Services

OHIP covers all or part of the costs of an ambulance service during a medical emergency.

A doctor must recognize your trip as medically necessary for coverage. If the ambulance is deemed required, then you will pay a co-payment of $45. If the ambulance was not medically necessary, then you will pay $240.

However, OHIP covers your ambulance transport if an Ontario hospital or health care facility deems it medically necessary to transfer you to another facility outside of Ontario but within Canada (when treatment is unavailable in Ontario).

There are exceptions to the co-payment requirement.

Seniors are exempt when they:

  • Receive provincial social assistance
  • Receive certain home care services
  • Live in a licensed long-term care home, home for specialized care, or home or residence for psychiatric patients

Patients receive the bill for their ambulance services from the hospital.

Physiotherapy Services

OHIP provides some access to physiotherapy for seniors aged 65 and older. You get access to services such as:

  • Out-patient physiotherapy clinics
  • Exercise and falls prevention classes
  • Assessment and treatment of injuries (work, motor vehicle accident, post-operative rehab, and chronic conditions)

However, many services, include chiropody, are fee-based.

You also need a referral from your nurse practitioner or doctor. You need to access the physiotherapy care at an OHIP-funded physiotherapy clinic.

Does OHIP Cover Prescriptions?

At present, everyone aged 65 and older receives coverage through the provincial Ontario Drug Benefit (ODB). The ODB requires partial payments depending on factors like income.

Starting August 1, 2019, the ODB covers 4,400 common prescription drugs for the 2.6 million Ontario residents 65 and over.

The coverage is full and no longer requires a co-payment or deductible. The government estimates that seniors will save an average of $240 on the cost of their prescriptions each year.

You can see if your prescriptions fall under the OHIP expansion by using the medication coverage search tool.

What Prescriptions Aren't Included?

Ontario doesn't cover all prescriptions. It infamously doesn't include oral or I.V. cancer drugs, which means you need to pay out of pocket.

In qualifying cases, your GP will fill out an exemption form to ask the province for permission to pay for your drugs.

The government makes decisions based on the severity and rarity of your illness as well as the cost of the drug.

Will You Need Long-Term Care?

Canadians have a ten percent chance of requiring long-term care by the time they reach 55. The number jumps to 30 percent by 65 and 50 percent by age 75.

While the OHIP expansion takes care of the bulk of common prescriptions, the biggest cause of concern is the need for long-term care.

At present, Ontario provides housing options for low-income senior Ontarians, including emergency rental assistance. There is also help for Aboriginal seniors.

However, long-term care is only subsidized - not covered- by the province.

The current monthly accommodation costs as of 2018 include:

  • Long-stay basic: $1,848.73
  • Long-stay semi-private: $2,228.63
  • Long-stay private: $2,640.78

Short-stay costs are $39.34 per day.

Seniors who don't have enough to cover the basic room can qualify for a subsidy. It can cover up to the full amount ($1,848.73) of basic accommodation.

Canadians can opt for long-term care insurance to help cover the costs of needing extra care.

Do Seniors Need More Insurance?

OHIP coverage for seniors handles the basics, but the little things it doesn't cover add up to thousands of dollars per year. Specialty and catastrophic drugs aren't covered by OHIP, and they can cost thousands of dollars - per month.

Three-quarters of all Canadians don't yet have a plan to pay for costly healthcare services or long-term care.

One way to cover these costs is to purchase private insurance.

Seniors, particularly those with present health issues, benefit both from private health insurance and life insurance.

Private health insurance companies offer plans tailored to those who receive more coverage from OHIP and have fixed incomes. These plans pick up where OHIP leaves off and cover:

  • Private and semi-private hospital rooms
  • Dental care
  • Optometry care
  • Travel insurance
  • Nursing care
  • Medical equipment
  • Vision care

In exchange for a premium, you'll know that you're covered in case an issue arises. Eliminating out-of-pocket costs can be a great source of stress relief, particularly if you live on a fixed income.

For example, if you have a cavity, it can cost you between $40 and $200 to take care of.

Health insurance allows you to confidently seek the care you need rather than risk putting it off, which becomes more problematic as you get older. This is particularly true for oral health, which is a predictor of your overall health and contributes to heart disease.

Additionally, you may find you benefit from a life insurance plan. Life insurance is always good to have, but it comes with riders like a long-term care rider that can help cover the cost of care homes.

You can also buy long-term care coverage on its own, but it tends to be more expensive. As the price of care and the number of people accessing it continues to grow, it's often more cost effective to combine life insurance and long-term care coverage.

Is OHIP Coverage for Seniors Enough?

OHIP coverage for seniors offers primary and essential care. You'll never receive a bill for making a medically necessary trip to the GP or hospital. Now that the province covers more than 4,400 prescription drugs, there are fewer out-of-pocket costs than before.

However, OHIP doesn't cover everything, and retirees still spend thousands of dollars a year on essential care.

Health insurance and life insurance are two methods that you can use when you begin financial planning for your retirement years. These will simplify costs and pick up where OHIP leaves off so that you don't need to make tough decisions about whether to get the care you need and deserve.

Are you looking for new health insurance? Click here to get a free quote and protect your financial future.

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