ONTARIO HEALTH INSURANCE PLAN(OHIP), ELIGIBILITY AND MEDICAL SERVICES COVERAGE
- Prof. (Dr) Usha
- Mar 3, 2023
- 4 min read
The Ontario Health Insurance Plan commonly known by the acronym OHIP is the government-run health insurance plan for Ontario. In Ontario, one needs a valid health card to get healthcare services covered by OHIP. Ontario's first government-run health plan, known as OMSIP (Ontario Medical Services Insurance Plan), was established and enacted on 1 July 1966. On 1 October 1969, it was replaced by OHSIP, the Ontario Health Services Insurance Plan, as a provincially-run and federally-assisted plan under the federal Medical Care Insurance Act for the establishment of a national medical plan. In 1972, its name was shortened to simply OHIP.
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. Through OHIP, the province pays for many of the health services one may need but not all. A valid health card is needed to get healthcare services covered by OHIP. Ontario residence need to apply and once get approved, they get an Ontario health card. The health card proves OHIP coverage for medical services– hence, one needs to show it every time while visiting a doctor, visiting an emergency room, or even have a medical test or going for surgery.
Who is eligible for OHIP in Ontario? To be eligible for OHIP one must:
Be a Canadian citizen or have immigration status as set out in Ontario's Health Insurance Act.
Have their permanent and main home in Ontario.
Be physically present in Ontario for 153 days in any 12-month period.
OHIP Schedule of Benefits and Fees
The OHIP Schedule of Benefits (often referred to as SOB) is the list of OHIP insured services that is used in Ontario. This information requires knowledgeable interpretation and is intended primarily for members of the professional health care community. The OHIP schedule of benefits lists every medical service that doctors are able to bill the Ontario government for. The OHIP Schedule of Benefits and Fees is not available in French. OHIP Fee Schedule Master – (For use with Billing Software) is effective July 9, 2021, and medical services are encouraged to update their Medical Billing Software accordingly. Each medical service is given a specific code, with a fixed dollar amount, that the government has agreed to pay the doctor for that service. There are a variety of different physician payment models throughout Canada. Which one a particular medical practice is on usually depends on where they are working and what payment model is used there.
Services covered by OHIP
OHIP covers many health services you may need. It covers part or all of the following services such as:
Appointments/ visits with your family doctor
visits to walk-in clinics and some other health care providers
visits to an emergency room
medical tests and surgeries
hospital visits and stays
medical or surgical abortions
eligible dental surgery in hospital- Some dental surgeries need to be performed in a hospital as they are complex and/or you have another medical condition that needs monitoring during the procedure.
eligible optometry (eye-health services)
podiatry (foot-health services)
ambulance services
travel for health services if you live in northern Ontario
To be covered by OHIP, one must have a medical reason to receive a service or treatment. Whether a client/patient visits his/her doctor, or if they see one in a walk-in clinic, OHIP covers the full cost of their services – as long as the services are medically necessary. Cosmetic surgery, for example, is not covered.
Services not covered by OHIP
OHIP does not 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
The Ontario Drug Benefit (ODB) program covers the cost of many medications, and one can avail these benefits if he/she has OHIP coverage, and are: age 65 or older, living in a long-term care home or a home for special care, receiving professional home and community care services, enrolled in the Trillium Drug Program or enrolled in Ontario Works or the Ontario Disability Support Program.
If a person has been out of Ontario for more than 212 days in any 12‑month period, they may have to reapply for OHIP at a specialized Service Ontario Centre that provides the full suite of health card services.
References:
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