What OHIP Covers and Does Not Cover2026-04-14T17:56:06+00:00
What OHIP Covers and Does Not Cover
The Ontario Health Insurance Plan covers medically necessary doctor and hospital services for all residents. But there are significant gaps. Here is a clear breakdown of what is covered, what is not, and what programs fill the gaps.
OHIP pays for medically necessary services provided by licensed physicians and hospitals. The full list is in the Schedule of Benefits, but the following are the most common covered services.
Family doctor and walk-in clinic visits
Specialist visits (with a referral from your family doctor)
Virtual care from your enrolled family doctor
Vaccinations recommended for your age group (flu shot, childhood vaccines, etc.)
Meals and standard accommodations during a hospital stay
Medications administered during a hospital stay
Outpatient surgeries and procedures
Private or semi-private rooms are not covered unless medically necessary. You can pay extra out of pocket for these upgrades.
X-rays, ultrasounds, mammograms
MRI and CT scans (when ordered by a physician)
Blood tests and other lab work ordered by a doctor
Cancer screening tests recommended for your age (Pap tests, colorectal cancer screening, mammograms after 50)
Some specialized tests like Prostate-Specific Antigen (PSA) are only covered under specific conditions (existing diagnosis, family history, etc.).
What OHIP Covers Partially or With Restrictions
Routine eye exams from an optometrist are covered under specific conditions:
Children and youth under 20One major eye exam every 12 monthsFree
Seniors 65 and overOne major eye exam every 18 monthsFree
Adults 20 to 64 with qualifying conditionsDiabetes, glaucoma, cataracts, retinal disease, etc.Free (annual)
Healthy adults 20 to 64Routine eye exams not covered~$100 to $150
Eyeglasses and contact lenses are never covered by OHIP for any age group.
Physiotherapy is covered only at approved community clinics and only for these groups:
• Children and youth under 20
• Seniors 65 and over
• People who were recently hospitalized (post-hospitalization recovery, up to 50 visits per year)
• Residents of long-term care homes (up to 100 visits per year)
• Recipients of the Ontario Disability Support Program (ODSP), Family Benefits, or Ontario Works
Adults aged 20 to 64 outside these categories pay out of pocket or use private extended health benefits. Sessions typically cost $80 to $150 each in private clinics.
OHIP covers $7 to $16 per visit to a registered podiatrist, up to a maximum of $135 per year, plus $30 for x-rays. The remaining cost is paid by you. Surgeries performed by podiatrists are not covered at all.
When an ambulance is medically necessary, OHIP covers most of the cost. You pay a $45 co-payment if the ambulance was called from your home or another non-medical location. If the ambulance trip starts at a medical facility (hospital transfer), there is no co-pay.
If the ambulance is deemed not medically necessary, you pay the full cost (typically $240 or more). The hospital decides this after assessing you on arrival.
What OHIP Does Not Cover
Routine dental care (cleanings, fillings, exams, root canals, extractions in a dental office) is not covered by OHIP. The only dental services covered are surgeries that must be performed in a hospital, such as fracture repairs, tumour removals, or medically necessary extractions with prior OHIP approval.
Two programs help with dental costs:
•Canadian Dental Care Plan (CDCP): Federal program that covers exams, cleanings, X-rays, fillings, and dentures for Canadians without private insurance whose household income is under $90,000.
•Ontario Seniors Dental Care Program: Free routine dental services for low-income seniors 65+ (annual income under $22,200 single or $37,100 couple).
Prescription drugs that you fill at a pharmacy and take at home are not covered by OHIP for most adults. You either pay out of pocket or use private extended health benefits.
However, several provincial drug programs fill the gap:
OHIP+ (under 25)Free coverage for 5,900+ medicationsNo enrolment
Ontario Drug Benefit (65+)Automatic at age 65, small co-pay per prescription$2 to $6 per Rx
Trillium Drug ProgramFor high drug costs relative to income, any ageApply
ODSP / Ontario WorksDrug coverage included with social assistanceAutomatic
OHIP+ does not require any application. If you are 24 or younger and do not have private insurance, just bring your health card to the pharmacy with your prescription. If you have private insurance, you must use that first.
Cosmetic surgery (unless medically necessary, such as reconstructive surgery after an accident)
Chiropractic care (no OHIP coverage for any age)
Massage therapy (not covered, even with a doctor's referral)
Acupuncture, naturopathy, homeopathy and other alternative treatments
Private psychotherapy from psychologists or social workers (only psychiatrists are covered)
Sick notes for work or school (most clinics charge $20 to $50)
Doctor's notes for insurance, employment, or driver's licence forms
Hearing aids (some assistance through the Assistive Devices Program)
Crutches, wheelchairs, and most assistive devices (partially covered through the Assistive Devices Program)
Long-term care home accommodation (medical care is covered but residents pay a monthly accommodation fee)
Retirement homes (no OHIP coverage at all)
Mental Health Coverage
Covered:
Visits with a psychiatrist (medical doctor specializing in mental health, requires referral from your family doctor)
Mental health support from your family doctor
Hospital-based mental health programs (inpatient and outpatient)
Crisis services through community mental health agencies
Ontario Structured Psychotherapy program (free CBT for anxiety and depression, referral or self-referral)
Not covered:
Private psychologists, social workers, or counsellors (typically $150 to $250 per session)
Online therapy platforms unless covered through Ontario Structured Psychotherapy
Coverage Outside Ontario
In other Canadian provinces or territories:
Medically necessary doctor and hospital services are covered at Ontario rates. Show your Ontario health card. Most provinces will direct-bill OHIP (you pay nothing). In Quebec, you typically need to pay upfront and submit a claim for reimbursement.
Outside Canada:
OHIP coverage is extremely limited. Emergency services are reimbursed at very low Ontario rates: doctor visits up to about $50 per day, inpatient services up to $200 per day, dialysis up to $210 per day. The actual cost in countries like the United States can be tens of thousands of dollars per day, leaving you responsible for the difference.
Always buy travel medical insurance before leaving Canada. Even a short hospital stay in the United States can result in bills of $50,000 or more. Travel insurance typically costs $5 to $20 per day depending on age and health.
Snowbirds and extended travel: If you leave Ontario for more than 7 months in any 12-month period, your OHIP coverage stops. There are exceptions for mobile workers, full-time students, and people who can prove their primary residence is still in Ontario. Confirm with ServiceOntario before travelling for extended periods.
Frequently Asked Questions
Can a doctor charge me for a service that is supposed to be covered by OHIP? +
No. The Commitment to the Future of Medicare Act prohibits charging patients for OHIP-insured services. If you are charged for a covered service, you can report it to the Ministry of Health. The ministry investigates and ensures any unauthorized payments are refunded.
Do I need to enroll in OHIP+ for prescription drug coverage under 25? +
No. There is no enrolment for OHIP+. If you are 24 or under and do not have private insurance, just bring your health card to the pharmacy. The pharmacist will check eligibility and bill OHIP+ directly.
Why does OHIP cover MRIs but not most prescription drugs? +
OHIP follows the Canada Health Act, which requires provinces to cover medically necessary hospital and physician services. Prescription drugs are not part of that mandate, so each province handles drug coverage differently. Ontario uses programs like OHIP+, ODB, and Trillium to fill the gap for specific groups.
Does OHIP cover circumcision for newborns? +
No. Routine non-medical circumcision was delisted from OHIP in 1994. Parents who choose to have their newborn circumcised pay out of pocket (typically $200 to $500). Medically necessary circumcisions related to specific health conditions are still covered.
Does OHIP cover gender-affirming care? +
Yes, for many services. OHIP covers hormone therapy prescriptions through OHIP+ for those under 25, and through ODB for seniors. It also covers gender-affirming surgeries when criteria are met and the procedures are performed at approved facilities. Coverage was significantly expanded in 2016 to include surgeries previously paid out of pocket.
Does OHIP cover at-home nursing or personal care? +
Some home and community care services are covered through Ontario Health atHome (formerly LHINs), based on assessed need. This includes nursing visits, occupational therapy, and personal support workers for people who are housebound, post-surgical, or living with chronic conditions. Contact 310-2222 (no area code) to request an assessment.
