What OHIP can and cannot do for you

The Ontario Health Insurance Plan (OHIP) pays for many health services you may need.

Every Ontario resident with his or her primary and permanent home in Ontario is entitled to access emergency and preventive care under OHIP free of charge. Ontario residents may go to a participating doctor – essentially every doctor practising in the province – any time they wish (subject to the consent of the doctor) and the services are billed through OHIP to the government. Whether you visit your doctor, or if you see one in a walk-in clinic, OHIP covers the full cost of your services – as long as they’re medically necessary.

OHIP does not generally cover:

• prescription drugs provided in non-hospital settings (e.g. antibiotics prescribed by your family doctor)
• dental services provided in a dentist’s office
• eyeglasses, contact lenses
• laser eye surgery
• cosmetic surgery

• As of 1 April 2019, the Ontario government will no longer offer free prescriptions to children and young adults with private insurance.

However, the Ontario Drug Benefit program pays for prescription drugs for seniors covered by OHIP and the Trillium Drug Program covers households with high prescription drug costs. As of 1 January 2018, prescription drugs for those under 25 years of age are covered by OHIP through OHIP+.

Hospital visits and stays

OHIP covers:

• doctor and nursing services
• services to diagnose what’s wrong (such as blood tests and x-rays)
• medications for in patients
• accommodation and meals if you have to stay

OHIP does not cover

• Once a patient is discharged from a hospital, prescribed medications are not covered (certain limited medications are provided to out-patients for home use)
• If you want a private or semi-private room, you or your private insurance will have to pay some or all of those hospital fees

Abortion services

OHIP covers:

• Surgical abortions that take place in a hospital or clinic
• Mifegymiso (a pill that induces an abortion in early pregnancy), if you have a prescription from your doctor

Dental surgery in hospital

Some dental surgeries need to be performed in a hospital because they are complex and/or you have another medical condition that needs monitoring during the procedure.

OHIP covers:

• fracture repair
• tumor removal
• reconstructive surgeries
• medically necessary tooth removal (prior approval by OHIP is required)

Optometry (eye-health services)

OHIP covers:

• The cost of one major eye exam (for vision and general eye health) every 12 months, plus any minor assessments you need, but only if you are19 years and younger or 65 years and older
• If you are 20 to 64 years old, and you have a specific medical condition affecting your eyes that requires regular monitoring, OHIP will cover a major eye exam for you once every 12 months and any follow-up appointments related to the condition.
• OHIP may also cover a major eye exam if it has been requested for a specific reason by your doctor (they will need to give you a referral form).

Podiatry (foot-health services)

• OHIP covers between $7-16 of each visit to a registered podiatrist up to $135 per patient per year, plus $30 for x-rays. You will need to pay for the remainder of the cost of each visit.
• OHIP does not cover surgeries performed by podiatrists.

Ambulance services

If you need an ambulance for a medical emergency, OHIP covers part or all the costs depending on the circumstances.

What OHIP covers elsewhere in Canada

Any service or treatment you receive in another Canadian province or territory must be medically necessary for it to be covered by OHIP. When you show your valid Ontario health card in another Canadian province or territory, you will be covered for some of the same services you’re covered for in Ontario including:

• physician services (e.g. visit to a walk-in clinic)
• services provided in a public hospital (e.g. emergency, diagnostic, laboratory)

OHIP does not cover elsewhere in Canada

• services not covered in Ontario (e.g. cosmetic surgery)
• ambulance services (including transport and paramedic)
• prescription drugs and other drugs given outside a hospital
• home-care services
• fees charged by private hospitals or facilities
• diagnostic or laboratory services outside of a public hospital
• long-term care or residential services
• assistive devices (e.g. prosthetics)

What OHIP covers outside Canada

The Ministry of Health is re-instating OHIP coverage for out-of-country emergency hospital, health facility and doctor services retroactive to January 1, 2020 with the same reimbursement rates and the same coverage criteria that existed prior to the cancellation of the Out-of-Country Travellers Program. Emergency health services are those given in connection with an acute, unexpected condition, illness, disease or injury that arises outside Canada and requires immediate treatment.

OHIP does not cover

OHIP does not cover ambulance services outside Canada.

Ontario residents are encouraged to purchase supplementary insurance when traveling outside Canada as many emergency health services provided outside the country cost much more than OHIP may pay.

Away for more than 7 months

You may be out of the province for up to 212 days in any 12-month period and still maintain your Ontario health insurance coverage provided that you continue to make Ontario your primary place of residence. If you plan to be outside Canada for more than seven months in any 12-month period you can keep your OHIP coverage for up to two years if you:

• have a valid health card
• make Ontario your primary home
• will be in Ontario for at least 153 days a year in each of the two years immediately before you leave the country

Sources:

• https://www.ontario.ca/page/what-ohip-covers#section-9
• https://www.ontario.ca/page/ohip-coverage-across-canada
• https://www.ontario.ca/page/ohip-coverage-while-outside-canada