What Does OHIP Not Cover? Gaps Ontarians Pay for Out of Pocket

What does OHIP not cover? Mostly the care that happens outside a doctor's office or a hospital bed. The big gaps are prescription drugs from a pharmacy, dental work, glasses and most adult eye exams, and paramedical care such as physiotherapy, massage and chiropractic. Ontario fills some of these gaps with programs based on age and income. Private health and dental insurance fills the rest.

What does OHIP not cover? The quick answer

OHIP covers medically necessary doctor and hospital services. It doesn't cover prescription drugs outside hospital for most adults aged 25 to 64, dental care in a dentist's office, glasses or contact lenses, or routine eye exams for adults aged 20 to 64. Most physiotherapy, massage, chiropractic and private therapy isn't covered either.

Ambulance trips and emergency care outside Canada are only partly covered. For each gap, check whether a public program covers someone your age and income. If not, you pay or claim through a plan.

OHIP coverage list: 25 common services (October 2026)

The clearest way to answer what does OHIP not cover is service by service. This table is based on Ontario Ministry of Health pages checked in October 2026. "Partly covered" means a provincial program pays only part of the cost, or covers only some people.

Ontario Ministry of Health and Ontario Health pages, checked October 2026. Rules and amounts change, so confirm on the linked page before you book or buy. This guide covers Ontario only.

The pattern is clear. OHIP pays for doctors and hospitals, and the services not covered by OHIP are mostly in the community: the pharmacy, the dental chair, the optometrist and the clinic.

Does OHIP cover prescriptions? Drugs outside hospital

Not for most working-age adults. Once you fill a prescription at a pharmacy, OHIP itself doesn't pay. Ontario's separate drug programs depend on your age, income and situation.

• OHIP+ (24 and under). OHIP+ covers over 5,000 drug products at no cost for people 24 or younger who aren't covered by a private plan. It ends on your 25th birthday, or sooner if a private plan covers you.
• Ontario Drug Benefit (65 and over). You join automatically the first day of the month after you turn 65. You pay a $100 deductible each program year (August 1 to July 31), then up to $6.11 per prescription. Lower-income seniors can apply to the Seniors Co-Payment Program, which waives the deductible and lowers the co-payment to $2.
• Ontario Drug Benefit (other groups). It also covers long-term care residents, people receiving professional home care services and people on Ontario Works or ODSP, says Ontario's drug coverage page.
• Trillium Drug Program (high drug costs). Trillium helps households whose drug costs are high for their income. For most people, the yearly deductible is about 4% of after-tax household income, paid in four quarterly amounts. Once a quarter's amount is met, you pay up to $2 per prescription.

As an illustration of the 4% rule, a household with $60,000 of after-tax income would face a deductible of roughly $2,400 a year, or about $600 a quarter. If your income changes by 10% or more, you can ask Trillium to recalculate.

If you're 25 to 64 with no workplace plan, no public program pays for your drugs unless your costs are high for your income or you're on social assistance or home care. That's why drug coverage sits at the centre of most plans for health insurance in Ontario.

Does OHIP cover dental?

Only in hospital. OHIP pays for some medically necessary dental surgery done in a hospital. You pay for regular care in a dentist's office, such as check-ups, cleanings and fillings. Three public programs can help:

• Healthy Smiles Ontario. Healthy Smiles Ontario is for children and youth 17 and under from low-income households. You enrol through your local public health unit.
• Ontario Seniors Dental Care Program. The seniors dental program is for seniors 65 and older with income under a set limit and no other dental benefits, apart from the federal CDCP.
• Canadian Dental Care Plan (CDCP). The federal CDCP is for Canadian residents who filed last year's tax return, have adjusted family net income under $90,000 and have no access to private dental insurance. A co-payment may apply, depending on income.

Notice the catch: access to private dental insurance can make you ineligible for the CDCP and the seniors program. Check public eligibility before you buy a plan with dental. Our guides to Canadian Dental Care Plan eligibility and the Canadian Dental Care Plan vs private insurance walk through that choice. If you don't qualify, look at individual health and dental plans, which can pair dental insurance with drug and vision coverage.

Vision care and eye exams by age

OHIP covers eye exams based on age and medical need:

• 19 and under: one major eye exam every 12 months.
• 20 to 64: a major eye exam every 12 months only if you have an eligible medical condition affecting your eyes. Otherwise, you pay the optometrist.
• 65 and over: one major eye exam every 18 months, or every 12 months if you have an eligible condition.

Glasses and contact lenses aren't covered at any age. Neither are upgraded lenses meant to reduce your need for glasses after cataract surgery, or their extra tests, even when the surgery itself is covered. People on ODSP have separate vision benefits.

Does OHIP cover physiotherapy? Physio, massage, chiropractic and therapy

Only for some people. You can get government-funded physiotherapy at a community clinic if you're:

• 65 or older
• 19 or younger
• any age, within 12 months of an overnight hospital stay or day surgery, for the condition you were treated for
• receiving Ontario Works or ODSP

Otherwise, you pay the clinic or claim through a plan. Other paramedical services work like this:

• Massage therapy isn't among the services OHIP lists as covered.
• Chiropractic care is uninsured in Ontario, a ministry bulletin confirms.
• Podiatry is partly covered. OHIP pays $7 to $16 of each visit to a registered podiatrist, up to $135 a year, plus $30 for x-rays. You pay the rest, and podiatric surgery isn't covered.
• Psychologists and psychotherapists in private practice aren't on that list either. Mental health care from a doctor, such as your family doctor or a psychiatrist, falls under OHIP's doctor services.

For adults 18 and older with depression or anxiety, Ontario Structured Psychotherapy offers publicly funded therapy with no out-of-pocket cost, from coached self-help to therapist-led sessions.

When you compare private plans, look at the yearly maximum for each type of practitioner, not just the list of services.

Ambulance co-payments, private rooms, travel and medical devices

Ambulance. Ontario doesn't bill for ambulance trips between Ontario medical facilities. A trip to hospital from home or another non-medical location carries a $45 co-payment, according to the Ontario seniors guide. People on social assistance, long-term care residents and some home care clients are exempt. Ambulance service in other provinces isn't covered.

Private rooms. OHIP covers a hospital stay in standard accommodation. For a private or semi-private room, you or your private plan pays some or all of the extra fees.

Travel. Outside Canada, OHIP pays set rates for some doctor and emergency services, only for an acute, unexpected condition. Emergency outpatient care is paid at up to $50 a day. Inpatient care is paid at up to $400 a day for a higher level of care, such as intensive care, or up to $200 a day for lower levels. The ministry warns that care in other countries costs more than OHIP may pay.

That gap is why travel insurance matters every time you leave the country. With a health condition, read our guide to travel insurance with pre-existing conditions, or start at our snowbird travel desk. Planning a long winter away? Check the provincial health coverage time-away rules first, because OHIP has its own limit on days outside Ontario.

Medical devices. The Assistive Devices Program helps people with a long-term physical disability who need a device for six months or longer. For mobility aids such as wheelchairs and power scooters, it pays 75% of the approved price. For hearing aids, it pays 75% of the cost, up to $500 per ear. People on Ontario Works or ODSP can get 100% of the approved price or maximum.

Long-term care. The province funds nursing and personal care in long-term care homes. Residents pay an accommodation co-payment, based on room type, with maximums the ministry sets each year, according to Ontario's paying for long-term care page. A rate reduction can help with a basic room. Costs beyond the public program are where long-term care insurance in Canada comes in.

How to fill the gaps: public programs first, then a private plan

Work through these in order:

1. Check the public programs. Match your age and income against OHIP+, the Ontario Drug Benefit, Trillium, Healthy Smiles, the seniors dental program, the CDCP, funded physiotherapy and Ontario Structured Psychotherapy.
2. Check every group plan you can reach, including a workplace, spouse's or retiree plan.
3. Fill what's left with private health and dental insurance. This matters most for contract workers, early retirees, families between jobs and anyone shopping for health insurance for self-employed people.
4. Buy travel insurance before you leave Ontario. No health and dental plan replaces it.

What does private coverage cost? Here are Instasure estimates for an Ontario mid-tier plan covering drugs, dental, vision and paramedical care.

Instasure estimates for example profiles (mid-tier plan, Ontario), as of October 2026. Modelled estimates, not quotes and not averages of plans sold.

The plan tier moves the price too. For the single 35-year-old, our model estimates about $55 a month for a basic plan with drugs and basic dental and no medical questions. A comprehensive plan with higher limits, major dental and broader paramedical cover comes to about $143 (Instasure estimates for that example profile, as of October 2026). If you just left a job, ask your former plan about conversion options before the deadline passes. Our guide to private health insurance cost in Canada has the full tier and age tables and a break-even check.

Health insurance outside Ontario

Every province runs its own public plan and programs, so these rules are Ontario's alone. If you live elsewhere, compare health insurance in BC, health insurance in Alberta, Manitoba or Saskatchewan. Our Quebec page is for information only, since advisor service isn't available there yet.

Michael's take

So what does OHIP not cover that should worry you most? As a planner, I'd split the gaps into two groups. The first is predictable costs: cleanings, eye exams, glasses and a few physio visits. You can budget for those, so compare a plan's premium with what your family actually spends. The second is costs you can't predict: a long-term medication, major dental work or a hospital bill abroad. Insurance earns its keep there, because those are the bills that pull money out of savings meant for a home or retirement.

My rule of thumb is to map the public programs before you buy anything. Children under 25 without a private plan already have OHIP+ for prescriptions, and a household under $90,000 with no dental plan may qualify for the CDCP. Buying a private plan without checking can switch off public coverage you would have had anyway. Then review the plan whenever your work changes, because leaving a job is when these gaps show up fastest.

Next steps

Get an instant health and dental estimate for your household in about a minute. Then compare plan types on our health and dental insurance page or the Ontario health and dental page. A licensed advisor in Ontario can then check which public programs you qualify for and compare insurers' plans for the gaps that remain. Estimates are model-based ranges, not quotes.