What is OHIP?

• 
  Louis DelSignore
  Lawyer

What is OHIP?

OHIP, or the Ontario Health Insurance Plan, is a government program that pays for many medical and healthcare services in Ontario. OHIP covers both emergency and preventative healthcare. To be eligible for OHIP, you must meet the following minimum qualifications:

• Be physically in Ontario for 153 days in any 12-month period
• Be physically in Ontario for at least 153 days of the first 183 days immediately after you began living in the province
• Make Ontario your primary residence.  

You must also meet at least one of the following additional requirements:

• Are a Canadian citizen
• Are an Indigenous person [Registered under the federal Indian Act]
• Are a permanent resident [Formerly called a “landed immigrant”]
• Are applying for permanent residence in Canada, and:
  • Have submitted an application to Immigration, Refugees and Citizenship Canada (IIRC) and;
  • IRCC has confirmed they have reviewed the application and that you meet the eligibility requirements to apply (see document requirements); and
  • You have not yet been denied
• Are in Ontario on a valid work permit and are working full-time in Ontario, for an Ontario employer, for at least six months
  • If you meet this requirement, your spouse and dependents may also qualify for OHIP
• Are in Ontario on a valid work permit under the federal Liv-in Caregiver Program
• Are a convention refugee or other protected person [as defined by Immigration and Refugee Board of Canada]
• Have a temporary Resident Permit
• Are a clergy member who can legally stay in Canada and will be ministering full time in Ontario for at least six months. [If you meet this requirement, your spouse and dependents may also qualify for OHIP]

What Does OHIP Cover?

OHIP covers a variety of health services that are medically necessary. Some examples of healthcare services that are covered include appointments with your family doctor, visits to walk-in clinics and some other healthcare providers, visits to an emergency room, medical tests and surgeries. Cosmetic procedures and services are not covered by OHIP. Many other services, such as eye-care and dental work, are only partially covered or receive no coverage.

To Maintain OHIP Coverage

You must be physically present in Ontario for 153 days in any 12-month period to maintain your OHIP coverage. 

Example: If between September 2021 to September 2022 you were physically present in Ontario for 153 days, you would not have to reapply for OHIP.

Exceptions for Short Absences

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

Before you leave, take the following items to the nearest ServiceOntario centre to make sure your OHIP coverage stays active:

• your health card
• proof of residency (e.g. mortgage, lease or rental agreement, property tax bill, valid driver’s licence)

Note: There are other exceptions for those who are studying or working outside of Ontario.

Reapplying for OHIP
If you’ve been out of Ontario for more than 212 days in any 12 month period, you may have to reapply for OHIP at a specialized ServiceOntario Centre.

To reapply for OHIP at the ServiceOntario Centre, you will need to bring these documents with you:

• a completed Registration for Ontario Health Insurance Coverage form
• three separate documents from the list of qualifying identification documents:
  • one original document that proves your Canadian citizenship or OHIP-eligible immigration status
  • one document (original, printed or digital/electronic document as noted on the list) that proves your residency in Ontario
  • one original document that proves your identity

There is no waiting period for OHIP. You can apply for coverage as soon as you arrive in Ontario.

OHIP and Out-of-Country Medical Procedures

OHIP only covers a very limited amount of the cost if you receive emergency health services while traveling outside of Canada. The treatment or service must meet all of the following criteria to qualify for out-of-country care:

• medically necessary
• provided at a licensed hospital or licensed health facility
• for an illness, disease, condition or injury that
  • is acute and unexpected
  • not pre-existing (you developed it outside of Canada)
  • requires immediate treatment

The government of Ontario recommends that you purchase private health insurance before leaving Ontario to cover any uninsured services you may need.

OHIP will cover the following amounts for out of country medical care:

Doctor services

OHIP will pay whichever of the following is less:

• the actual amount billed by doctor(s) who treated you outside Canada
• rates listed in and paid to Ontario physicians in the Ontario Schedule of Benefits for Physicians Services

Emergency outpatient services

OHIP will pay whichever of the following is less:

• up to $50 (Canadian) per day
• the amount billed by the hospital

Emergency inpatient services

OHIP will pay up to:

• $400 (Canadian) per day for services provided in:
  • an operating room
  • a coronary care unit
  • an intensive care unit
  • a neonatal or pediatric special care unit
• $200 (Canadian) per day for lower levels of care

Doctor Recommended Out-of-Country Medical Services

If your doctor recommends that you obtain out-of-country medical services, OHIP may cover some of the associated costs. To qualify, you must get written prior approval from the Ministry of Health before you receive services. Services that may be covered must be:

• Performed at a hospital or licensed health facility; and
• Not experimental or for research or for a survey; and
• Generally accepted in Ontario as appropriate for a person in the same medical circumstances as the insured person; and
• Either not performed in Ontario by an identical or equivalent procedure; or
• Performed in Ontario but the insured person must receive the services outside Canada to avoid a delay that would result in death or medically significant irreversible tissue damage.

For more information about OHIP visit the Government of Ontario’s websites:

• OHIP – What’s Covered; Who Qualifies; Applying to OHIP
• OHIP Coverage While Outside Canada

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This article was written by Personal Injury Lawyer Louis DelSignore and Articling Student Hannah Robbins. If you require assistance with a personal injury matter or wish to speak to a personal injury lawyer at McKenzie Lake Lawyers LLP, please call (519) 672-5666.