For residents of Ontario, the Ontario Health Insurance Plan (OHIP) provides essential, medically necessary coverage throughout a person's life. However, once an Ontarian reaches 65, their benefits expand to include a wider range of services and products, reflecting the increased healthcare needs that often come with age. Understanding these benefits is crucial for planning and accessing the care you need.
Core OHIP coverage for seniors
Many of the healthcare services covered by OHIP for the general population continue for seniors. These form the foundation of senior health benefits:
- Doctor and specialist visits: Services provided by family doctors and medical specialists are fully covered when medically necessary. This includes regular checkups, consultations, and chronic disease management, which are especially important for older adults.
- Hospital services: OHIP covers in-patient and out-patient hospital services, including emergency care, surgeries, diagnostic tests (such as X-rays and ultrasounds), and basic ward accommodation.
- Diagnostic tests: All medically required diagnostic tests, such as blood work and X-rays, are covered.
- Preventive care: Seniors can access a variety of preventive screenings at no cost, including cancer screenings (colorectal, breast), and immunizations recommended for their age group.
Enhanced senior benefits: What's new at 65+
Turning 65 unlocks specific benefits that significantly improve access to care, particularly for medications and specialized services.
Prescription drug coverage (Ontario Drug Benefit Program)
Upon turning 65, all Ontario residents with a valid health card are automatically enrolled in the Ontario Drug Benefit (ODB) program. This program covers most of the cost for over 5,000 prescription drug products. Most seniors pay a small deductible and a co-payment per prescription, but low-income seniors may be eligible for the Seniors Co-Payment Program which waives the annual deductible and lowers the co-payment.
Vision care
Eye care is an important benefit for seniors under OHIP, offering coverage for regular examinations and monitoring of age-related conditions. OHIP covers one major eye exam every 18 months for seniors 65 and older, along with two minor follow-up assessments. Exams for monitoring specific medical conditions, like glaucoma and cataracts, are covered more frequently.
Home care services
For seniors who require assistance to remain independent at home, OHIP provides access to a range of services coordinated through Ontario Health atHome. This includes professional services like nursing and therapy, as well as personal support for daily activities, based on a care coordinator's assessment.
Physiotherapy
OHIP covers physiotherapy for seniors aged 65 and older under specific conditions, which must be received at a designated, publicly-funded clinic. Coverage is for specific, functional needs with a doctor's referral.
Comparing seniors' OHIP benefits with other programs
| Feature | OHIP for Seniors (65+) | Ontario Seniors Dental Care Program (OSDCP) | Canadian Dental Care Plan (CDCP) |
|---|---|---|---|
| Eligibility | All Ontario residents 65+ with a valid health card. | Low-income seniors 65+ based on income thresholds. | Canadian residents 65+ based on household income. |
| Prescription Drugs | Access to Ontario Drug Benefit (ODB), covering approximately 5,000 drugs. | N/A | N/A |
| Vision Care | One major eye exam and two minor follow-ups every 18 months. | N/A | N/A |
| Physiotherapy | Covered at designated clinics for specific functional needs with a referral. | N/A | N/A |
| Dental Care | Limited to medically necessary dental surgery performed in a hospital setting. | Covers most routine and major services, including dentures, for eligible low-income seniors. | Provides tiered coverage for basic and major dental services for eligible seniors. |
| Assistive Devices | Partial coverage for some devices through the Assistive Devices Program (ADP). | N/A | N/A |
| Home Care | Covered for professional and personal support services, assessed by Ontario Health atHome. | N/A | N/A |
What is not typically covered?
While robust, OHIP does not cover everything. Seniors should be aware that routine dental care, hearing aids, and most assistive devices are generally not covered, although programs like the Ontario Seniors Dental Care Program and the Assistive Devices Program can provide financial assistance. Private or semi-private hospital rooms are not fully covered, and ambulance services may have a fee if not deemed medically necessary.
Conclusion
Upon turning 65, Ontario residents gain access to an expanded set of healthcare benefits under OHIP and complementary provincial programs like the Ontario Drug Benefit and Ontario Seniors Dental Care Program. This includes robust coverage for medically necessary hospital and doctor services, plus enhancements for prescription drugs, eye exams, home care, and specific physiotherapy needs. By understanding the full scope of these offerings and the limitations, seniors can effectively navigate the healthcare system and address their health and wellness needs. It is important to check eligibility for other programs, particularly for dental and drug costs, to maximize benefits.
For more information on provincial healthcare programs, visit the official Ontario.ca website.
How to maximize your benefits
To make the most of the healthcare options available to you, consider the following steps:
- Confirm your eligibility: While most benefits are automatic upon turning 65, some, like the Seniors Co-Payment Program for low-income seniors, require a separate application.
- Use specific programs: Always check if you are eligible for programs beyond standard OHIP, such as the Ontario Seniors Dental Care Program, to cover services not included in core OHIP.
- Find designated clinics: If you need OHIP-funded physiotherapy, ensure you visit a designated clinic and have a doctor's referral.
- Connect with a care coordinator: If you require home care services, contact Ontario Health atHome to arrange for a needs assessment.
- Consider supplemental insurance: For services not covered by OHIP, like vision correction and most dental work, private supplemental insurance can help fill the gaps.
Understanding the Ontario Drug Benefit Program
Upon turning 65, seniors are automatically enrolled in the Ontario Drug Benefit (ODB) program. This program provides significant coverage for over 5,000 prescription drug products with income-based co-payments. Low-income seniors can apply for the Seniors Co-Payment Program to further reduce costs. Prescription coverage requires a valid Ontario health card and filling prescriptions at an Ontario pharmacy. You can search online to confirm if a specific medication is covered by the ODB.
Resources for seniors over 65
- Ontario Health atHome: Coordinates OHIP-funded home care services.
- Assistive Devices Program (ADP): Offers partial coverage for assistive devices.
- Ontario Seniors Dental Care Program (OSDCP): Provides dental coverage for low-income seniors.
- Canadian Dental Care Plan (CDCP): Offers coverage for basic and major dental services to eligible seniors 65+.
- Seniors Co-Payment Program: Reduces drug costs for low-income seniors enrolled in the ODB.
