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 Ontario Health Card.
To be eligible for health coverage in Ontario you must all of the following minimum criteria:
- 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.
You must also meet at least one of the following additional criteria:
- are a Canadian citizen
- are an Indigenous person (registered under the federal Indian Act)
- are a permanent resident (formerly called a “landed immigrant”)
- have applied for permanent residence, and Immigration, Refugees and Citizenship Canada has confirmed that:
- you meet the eligibility requirements to apply
- you have not yet been denied
- are in Ontario on a valid work permit and are working full-time in Ontario, for an Ontario employer, for at least six months
- your spouse and any dependents also qualify if you do
- are in Ontario on a valid work permit under the federal Live-in Caregiver Program
- are a convention refugee or other protected person (as defined by Immigration and Refugee Board of Canada)
- have a Temporary Resident Permit (only certain case types, e.g. 86 through 95)
- are a clergy member who can legally stay in Canada and is ministering full time in Ontario for at least six months
- your spouse and any dependents also qualify if you do
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.” This includes, but is not limited to:
- visits to general practitioners and specialists
- basic hospital costs for medically necessary procedures; medications for patients in hospital
- abortion services
- certain dental surgery done in hospital
- part of the cost of a visit to a registered podiatrist per year
- ambulance services (under certain conditions)
What is not covered by OHIP?
OHIP does not cover prescription drugs provided in non-hospital settings, such as antibiotics prescribed by your family doctor. There are common types of treatment that are also 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.
For more information on what services are covered by OHIP, visit ontario.ca.
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 5,000 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
For more information on OHIP+ and the drugs covered, visit ontario.ca.
Seniors and OHIP coverage: Ontario Drug Benefit (ODB) program
Seniors (people age 65 and older) who have a valid Ontario Health Card qualify for the Ontario Drug Benefit (ODB). When you reach the age of 65, the Government will send you a letter about three months before your 65th birthday telling you that you will automatically join the Ontario Drug Benefit program on the first day of the month after you turn 65 years old.
The ODB program covers most of the cost of 5,000+ prescription drug products. Prescriptions must be filled in an Ontario pharmacy to be covered. Along with prescription medication, the program also covers other services, including:
- pneumonia vaccination
- allergy shots and EPIPen
- one comprehensive eye exam every 12 months
In some cases, individuals may qualify before they reach the age of 65, for instance if they live in a:
- long-term care home
- home for special care
- Community Home for Opportunity
For more information, refer to the Ontario government website on the Ontario Drug Benefit program.
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 who qualifies for OHIP and how to apply, 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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