In Ontario, one-third of employees don't get dental and medical benefits through their employer. And while Ontarians are covered for many medical costs by the government-funded insurance plan, there is still a big, expensive gap.
Navigating health insurance in Ontario can be overwhelming, especially when you're trying to understand what OHIP covers, where it falls short, and how private insurance can bridge the gaps. With rising healthcare costs and evolving insurance policies, having the right health coverage is more important than ever.
This guide will provide a detailed breakdown of health insurance options in Ontario, including OHIP coverage, private insurance plans, cost comparisons, and actionable tips for choosing the right policy. Whether you're a student, retiree, self-employed professional, or just someone exploring health coverage options, this article has you covered.
By the end, you'll have a clear understanding of how to maximize your health coverage and ensure financial peace of mind in case of medical emergencies.
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Why Do You Need Health Insurance in Ontario?
In Ontario, all residents have access to the Ontario Health Insurance Plan (OHIP) paid for by the government. But OHIP doesn't cover everything you may need.
OHIP covers many health services such as doctor appointments, emergency room visits, and medical tests and surgeries. It does not cover prescription medication, dental clinic services, optometrist visits, and prescription eyewear nor cosmetic surgery. OHIP covers one major eye exam every 24 months for youth under 19 years old as well as seniors over 65.
As you can see, there are many things that you may need to access regularly that is not covered by OHIP. Prescription medicines, dental work, and eyeglasses are common items families need. Some employers provide additional coverage, but not all do.
To make up the difference, there are several health insurance providers in Ontario. That way you know you are financially prepared for any unexpected illnesses that come up.
Private Health Insurance in Ontario
Private health insurance serves as a safety net, covering services not included in OHIP. Many Ontarians opt for private insurance to ensure comprehensive healthcare coverage.
Types of Private Health Insurance Plans:
- Extended Health Benefits: Covers medications, equipment, and alternative therapies.
- Dental Insurance: Includes routine and emergency dental care.
- Critical Illness Insurance: Financial protection for severe medical conditions.
- Travel Insurance: Coverage for medical emergencies abroad.
- Disability Insurance: Provides income protection in case of long-term disability.
Who Needs Private Insurance?
- Freelancers and self-employed individuals
- Retirees
- International students
- Employees without group coverage
Benefits of Private Insurance:
- Coverage for prescription drugs
- Shorter wait times for specialists
- Access to private hospital rooms
- Financial protection from unexpected medical costs
Example: Sarah, a retiree, saved thousands on vision care and dental surgeries through her private insurance plan.
Comparing Private Health Insurance Providers in Ontario
Choosing the right insurance provider is essential to maximize benefits.
Key Comparison Factors:
- Premium Costs: Monthly and annual fees.
- Deductibles: Out-of-pocket costs.
- Coverage Limits: Annual and lifetime maximums.
- Network of Providers: Ensure your preferred healthcare professionals are included.
Here are some of the major health insurance providers in Ontario:
Blue Cross Ontario Plans
Blue Cross Ontario offers several packages to suit your unique needs. There is no deductible for any of the items you can buy.
All plans include a pay-direct drug card. All plans also come with $5 million emergency travel medical coverage.
Basic Blue Choice
This plan is for those aged 16 through 74. For prescription drugs, this plan gives you 70% coverage up to $500 per calendar year per person.
You also get 70% coverage for dental care for a total of up to $245 per calendar year per person. Vision care is not included in this package.
Basic Plus+
This plan gives you more dental benefits. You get up to $500 per person each year.
Prescription coverage also goes up to 80% per year. In your first year of coverage, you are covered for up to $500. In following years you are covered for up to $750.
This plan gives you access to eye exams up to $50 every two years. This coverage doesn't cover prescription glasses.
Blue Choice Balance
If you are going to need a high threshold for prescription medication, this plan is a good option. You get 70% coverage up to $5000 per calendar year.
Dental benefits in this plan allow you up to $500 per person each year.
Vision care in this plan allows you up to $100 every two years. And you are eligible for an eye exam costing $50 every two years.
Blue Choice
The Blue Choice package lets you choose only the benefits you need. The prescription coverage is 80% for a total of $10,000 per calendar year.
Vision care in this plan allows you up to $150 every two years. And you are eligible for an eye exam costing $50 every two years.
Dental coverage goes up each year. During year one, you get 70% up to $750.
Year two allows you 75% coverage up to $1000. In year three, coverage is 80% for a total of $1,250 per year.
Sunlife Health Insurance Ontario Plans
Sun Life Financial is an award-winning company that has won a place among the 2018 Global 100 Most Sustainable Corporations in the World.
They offer three options for health plans.
Basic Plan
This plan is a low-cost option that provides basic dental and medical coverage.
You get 60% reimbursement for prescription drugs and dental care. The drug maximum is $750 a year. The dental annual maximum is $500.
There is no vision care in this plan.
Standard Plan
This is Sunlife's most popular plan. It is a good option for those who want catastrophic drug and emergency travel medical coverage.
Prescription drug coverage is 70% up to $7000. After you hit that threshold, you will get 100% coverage for another $93,000 of eligible expenses.
The standard plan allows you to have 100% coverage for supplemental healthcare. This includes naturopathic services, registered massage therapists and so on. There is a $300 maximum per year.
You are eligible to get 100% coverage for vision care up to a maximum amount of $150 every two years.
Enhanced plan
The enhanced plan offers extensive and comprehensive coverage. This plan has optional dental coverage that includes orthodontic and restorative services.
Coverage is 80% for prescription drugs for first $5,000. Then you are covered for 100% of the expenses up to $245,000 a year. If you think you may need extensive coverage, you should consider critical illness insurance.
You get 100% coverage for supplemental healthcare up to a max of $400 per year. The vision care threshold is $200 every two years and is 100% reimbursable.
Manulife Health Insurance
Manulife also offers a multitude of health and dental products to suit a variety of situations and budgets, such as:
Manulife Flexcare
This plan, as the name implies, allows you to choose the services that you need. There are also customizable add-ons. This way you can create a plan that is tailored to your needs.
Coverage depends on what features you choose.
Manulife FollowMe
If you are leaving a job and will no longer have access to a group benefits plan with Manulife, this plan is for you.
This plan allows you to keep the coverage that you are used to.
Manulife Association
This third Manulife plan has four options to choose from. Each provides higher coverage than the other plans offered by Manulife.
Coverage includes prescription drugs, dental care, vision care, hospital coverage, and travel.
How to Choose the Right Health Insurance Plan
Selecting the best plan requires evaluating your health needs and financial capacity.
Steps to Choose a Plan:
- Assess Your Needs: Do you need dental, vision, or extended health benefits?
- Compare Policies: Look at costs, deductibles, and coverage limits.
- Read the Fine Print: Be aware of exclusions and limitations.
- Seek Professional Advice: Consult an insurance broker if needed.
Pro Tip: Avoid plans with extremely low premiums, as they often come with high deductibles and limited coverage.
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Understanding the Ontario Health Insurance Plan (OHIP)
The Ontario Health Insurance Plan (OHIP) is a government-funded health insurance program that provides residents with access to essential healthcare services without direct costs.
Key Features of OHIP:
- Doctor Visits: Covers consultations with general practitioners and specialists.
- Hospital Stays: Includes standard accommodations and medically necessary treatments.
- Diagnostic Services: Covers blood tests, X-rays, and other essential diagnostics.
- Emergency Care: Provides coverage for critical medical situations.
Who is Eligible for OHIP?
To qualify for OHIP, you must:
- Be a Canadian citizen, permanent resident, or hold a valid work permit.
- Reside in Ontario for at least 153 days per year.
- Make Ontario your primary residence.
How to Apply for OHIP
- Visit a ServiceOntario center.
- Bring supporting documents (e.g., proof of residency, identification, immigration status).
- Complete the OHIP registration form.
- Wait for your OHIP card to arrive.
Common Misconceptions About OHIP
- OHIP Covers Everything: False. Many services, including prescription medications, are excluded.
- Immediate Coverage: New residents may experience a waiting period.
- Out-of-Province Coverage: Limited to emergencies only.
What OHIP Does Not Cover
While OHIP offers extensive coverage, there are significant gaps in services that it does not include.
Key Exclusions:
- Prescription Medications: Unless you're covered under the Ontario Drug Benefit (ODB) program.
- Dental Care: Routine cleanings, fillings, and orthodontics are not covered.
- Vision Care: Adults under 65 are not covered for eye exams or glasses.
- Paramedical Services: Physiotherapy, chiropractic care, and massage therapy.
- Private Hospital Rooms: Only covered if deemed medically necessary.
Example: John, a freelancer, required dental surgery that cost $2,500 out-of-pocket because OHIP did not cover the procedure.
Why These Gaps Exist
OHIP is designed to cover medically essential services, leaving supplementary healthcare to private insurance providers.
Frequently Asked Questions (FAQs)
Here are some of the most commonly asked questions about health insurance in Ontario:
No. OHIP does not cover prescription drugs, dental care, or vision care.
Yes. Private insurance complements OHIP.
Costs vary based on coverage, age, and provider.
Final Thoughts
Understanding health insurance in Ontario doesn’t have to be complicated. With OHIP offering essential services and private insurance filling in the gaps, you can secure comprehensive healthcare coverage tailored to your needs.
As you can see there are many options for health insurance plans in Ontario. This article just covers the plans of three of the major providers in Ontario. The best way to get the best deal on health insurance plans is to compare prices and packages. Get a quote to get the lowest insurance rates in Canada.
