Area of Law: Health Law
Answer # 695
Who and what are covered by OHIP?Region: Ontario Answer # 695
Who is eligible for health care?
Canada maintains a universal health care system that provides health care services paid for by money collected from taxes. In Ontario, the government administers the Ontario Health Insurance Plan, commonly called OHIP, which generally pays for health care services received by Ontario residents with a valid health card.
Generally, to be eligible for health coverage in Ontario you must meet all of the following criteria:
- be a Canadian citizen, permanent resident or among one of the newcomer to Canada groups who are eligible for OHIP as set out in Ontario’s Health Insurance Act;
- be physically present in Ontario for 153 days in any 12-month period;
- be physically present in Ontario for at least 153 days of the first 183 days immediately after establishing residency in the province; and
- make Ontario your primary place of residence.
What is covered by OHIP
Under the federal Canada Health Act, provincial and territorial governments must insure or cover “medically required” services provided by medical practitioners and insure certain hospital services if they are “medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness, or disability.” Generally, this includes visits to general practitioners and specialists, as well as basic hospital costs for medically necessary procedures.
There are common types of treatment, however, that are not insured by OHIP or are only partially insured. Generally, dental treatment is not covered by OHIP and must be paid for by the patient or their private insurance company. Treatment by a physiotherapist is only insured by OHIP under certain situations, such as if you are aged 19 or younger, or 65 or older and require in-home physiotherapy or are living in a long-term care home. Check with the Ministry of Health and Long-Term Care for a complete list of who is eligible.
Further, some administrative costs are also not covered, such as the cost of missed appointments, and the cost for having a doctor fill out forms or write letters at the request of patients.
Chiropractic care is not insured by OHIP but can be by private health care plans. Also, if you receive chiropractic care because of a recent car accident, you will usually be able to recover the costs from your car insurance company.
For most adults, routine eye examinations which are provided by either an optometrist or physician, are not covered by OHIP. However, there are exceptions for certain people. For example,
- Low income residents, such as those receiving assistance through the Ontario Disability Support Program (ODSP), Ontario Works, or the Family Benefits Program are covered for a routine eye exam once every two years,
- Seniors 65 years of age or older, children, and those adults who are younger than 20 years old, are covered for a routine eye exam once every 12 months plus any follow-up assessments that are needed, and
- People with specific medical conditions or diseases which affect the eyes, such as glaucoma, cataract, and diabetes mellitus, are insured for regular eye examinations. To find out if you are insured for a regular eye exam based on your medical conditions, check with the Ministry of Health and Long-Term Care or speak with your health care provider.
OHIP+ Children and Youth Pharmacare Plan
Under Ontario’s OHIP+ plan, anyone who is 24 years old and younger who is covered by OHIP and is not covered by a private insurance plan does not have to pay for prescriptions for more than 4,400 drug products currently available through the Ontario Drug Benefit (ODB) plan. Individuals do not have to enrol in the program, as coverage is automatic and ends on the individual’s 25th birthday.
Medications covered include:
- asthma inhalers,
- diabetes test strips,
- oral contraceptives,
- cancer drugs and drugs for rare diseases
- antibiotics for infections,
- mental health drugs, and
- attention deficit hyperactivity disorder drugs
Services received outside of Ontario
Even if an Ontario resident receives health services in Canada but outside of Ontario, they will normally be insured. However, residents may only be covered or partially covered for certain services. The province or territory you are visiting will usually bill the Ontario Ministry of health directly for most services, such as hospital and physician services. However, in Québec, you may have to pay for physician services and then submit your receipt to the Ministry office for payment.
For more information on OHIP+ and the drugs covered, visit ontario.ca.
For additional information about the services and treatments that are insured by OHIP, contact the Ministry of Health and Long-Term Care.
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