OHIP: What's NOT Covered

If you live in Ontario, you probably know that OHIP (the Ontario Health Insurance Plan) pays for doctor visits. But what about other things like prescription drugs, physiotherapy, ambulances, or surgery? Many people trust and use health care treatments such as Chinese medicine, acupuncture and homeopathy. Does OHIP cover them? And do you really need extra health insurance for your family?

A recent injury I suffered raised some of these questions for me, and prompted me to call the Ministry of Health and Long Term Care. David Jensen, spokesperson for the Ministry, helped sort out this complex issue.

In general, said Jensen, "OHIP provides funding for medically necessary physician services, certain dental services that are required to be performed in a hospital, and certain practitioner services that are therapeutically necessary." Beyond that, OHIP may pay for other medical services and products, but a number of other factors come into play: for example, your age, your source of income, and whether or not you've just spent a night in a hospital.

Prescription Drugs

OHIP does not usually cover prescription drugs, said Jensen. However, if you need medicine when you're in the hospital, there is no direct charge to you. Also, Ontario Drug Benefit program for certain groups: if you're over 65, if you're on Ontario Disability Support Program and/or Ontario Works, if you live in a long term care home and homes for special care, or if you're receiving professional home care services. Even so, you may need to pay a small fee when you get a prescription. If you're not in these categories, you may apply to the Trillium Drug Plan, depending on your income.

Even if you do qualify for help with drug payments, though, not all drugs are covered by OHIP. We occasionally hear about people fighting for new cancer medication, for example. That's because OHIP only pays for drugs listed on the Ontario Drug Benefit Formulary. Some drugs, especially newer ones, aren't on it, at least not yet.

Physiotherapy and Other Services

OHIP rules change from time to time. Physiotherapy coverage, for example, changed in 2005. Jensen explained that Ontarians aged 20 to 64 are covered "if they require physiotherapy after overnight hospitalization, if they require services in their home or if they reside in a long-term care home. All Ontario Disability Support Program, Family Benefits and Ontario Works recipients are covered regardless of age. All other people aged 20 to 64 no longer receive coverage for physiotherapy." Since 2004, OHIP no longer pays for chiropractic services.
OHIP covers mental health services provided by a doctor, but if you choose to visit a counsellor without the recommendation of a doctor, you'll need to pay for the service.

Sometimes OHIP puts a cap on what they'll pay each year. For example, they will cover up to $135 per year for non-surgical services by qualified podiatrists. Beyond that, you'll have to pay.
And occasionally OHIP covers some services but not others that are related. If you have both fallopian tubes blocked, for example, OHIP will pay for three In Vitro Fertilization cycles, but not for lab fees.

Chinese medicine, naturopath medicine, acupuncture, homeopathy and Reiki services are not covered. On the other hand, OHIP does pay for medically necessary nutrition and diet counselling and, interestingly, hypnosis services provided by a physician.

Do you want help to quit smoking? Usually it's not covered, but a study called the Smoking Treatment for Ontario Patients program has paid for counselling and nicotine replacement therapy in the past. It may open again at some point. You can check at www.stopstudy.ca

I was surprised to learn that ambulances are not fully covered by OHIP. In most cases, if you use one, you'll need to kick in $45; the hospital will bill you. OHIP pays the rest. If the doctor at the hospital says that an ambulance was unnecessary, you will have to pay the full cost, $240 – an expensive trip – but a small price to pay if there's any chance your life is in danger.

At The Hospital

If a doctor decides that you need surgery, OHIP covers the cost of the operation and any medication you'll require during your stay, but in most cases you will have to buy your own crutches, casts, splints, etc. If, however, you have a long-term physical disability, you may get help from the Assistive Devices Program. Also, in hospital, expect to pay for your own telephone, television, and private room but most basic hospital stays are covered.

Some surgeries are covered in certain situations but not others. For example, Jensen explained, "Circumcision is an insured service only when medically necessary. As such, circumcision performed for ritual, cultural, religious or cosmetic reasons at any age is not an insured service."

Dental and Eye Care

If you have dental surgery in a hospital, it's covered. However, treatments given in a dentist's office (fillings, caps, etc) are not normally covered by OHIP, unless you receive social assistance.

Similar guidelines apply to eye care. Cataract eye surgery, laser treatment for retinal tears, and appointments with eye specialists are covered. General eye exams by optometrists or ophthalmologists used to be covered for everyone until 2004, when the rules changed. Children, seniors and people on social assistance are still covered. If you have certain diseases like diabetes mellitus, glaucoma, cataract, retinal disease, etc., OHIP pays for your eye exams. Otherwise, expect to pay for them yourself.

Protect Yourself

Extra health costs can add up quickly. If you're lucky, you may already have health benefits through your job. If not, you can buy private insurance on your own, or set up an emergency savings fund for this purpose.

The high cost of extra medical services is just another reason to take care of yourself. Although you can't put a price on health, an ounce of prevention may save you thousands of dollars in the future.

For more information: www.health.gov.on.ca/en/public/programs/ohip/