What does health insurance cover in Canada — and what are you paying for yourself?

If you’ve ever wondered what health insurance actually covers in Canada, you’ve come to the right place. We’ll break down what services it does and does not include, as well as the difference between private coverage and provincial or federal programs.

Does Canada have free health care?

Health care in Canada is often referred to as universal or free, since you are not left with a co-payment for most medical services. But that isn’t because the services are completely free — rather, you have already paid into the system through taxes.

This stems from the Canada Health Act (1), which sets the national standards that each province and territory must follow. To receive federal funding for healthcare, provincial plans must be:

• Universal
• Accessible
• Portable
• Comprehensive
• Publicly administered

But surprisingly, there’s no single national plan for Canadian health care. Instead, Canada has thirteen separate provincial and territorial systems, with each jurisdiction determining what is deemed “medically necessary”.

What does provincial health insurance deem medically necessary?

Across Canada, all provincial and territorial public plans must cover:

• Hospital services (including surgery, nursing care and diagnostics)
• Physician services
• Surgical-dental procedures performed in a hospital
• Certain diagnostic tests

For example:

• In Ontario, the Ontario Health Insurance Plan (OHIP) covers doctor visits and hospital care (2)
• In BC, the Medical Services Plan (MSP) covers physician and surgeon services, plus any dental or oral surgery performed in a hospital (3)

For expectant parents, pregnancy care is broadly covered by the public healthcare system, including prenatal visits and a hospital delivery. However, the option of having a private hospital room is usually not covered.

Mental health care is partially covered: visits to a family doctor or psychiatrist are included, but sessions with a psychologist or therapist generally are not.

What about emergency care away from home?

Travelling within Canada is usually safe. Your provincial plan will follow you as long as you stay within the country. Most provinces will bill each other directly from the hospital or the physician’s office.

The one exception is Quebec. Unlike other provinces, you may need to pay for your medical services up front and request reimbursement from your insurer when you return home.

If you leave Canada, the coverage is limited. It’s always advisable to get proper travel medical insurance before leaving on an international trip.

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What does provincial health insurance NOT cover?

This is where many Canadians are caught off guard. Universal healthcare does not mean complete coverage, and there are some pretty big gaps in the provincial healthcare systems.

These are the big three areas that are NOT covered under provincial health insurance:

• Dental care (cleanings, fillings, exams)
• Prescription drugs (outside hospitals)
• Vision care (for most adults 20 to 64)

These are the services that most Canadians will use at least once per year.

Other medical services that are usually not covered include:

• Physiotherapy and chiropractic care
• Psychologists and therapists for mental health issues
• Medical equipment (orthotics, prosthetics)
• Home care, assisted living and private nursing

What does that look like for the average Canadian? A typical resident with a comprehensive workplace plan can offset close to $2,000 a year in out-of-pocket expenses.

Also, remember that coverage isn’t the same across the nation. Since provinces decide what qualifies as “medically necessary,” you could be paying more or less depending on where you reside.

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What is the Canadian Dental Care Plan — and do you qualify?

A significant recent addition for Canadians is the Canadian Dental Care Plan (CDCP) (4). This is a federal program designed to provide access to proper dental care while removing financial barriers for individuals without private coverage.

To qualify for CDCP, you must:

• Be a Canadian resident
• Have no access to private dental insurance (through an employer or spouse)
• Have an adjusted family net income under $90,000
• Have filed your tax return with the CRA for the previous year

CDCP coverage uses a co-payment structure which depends on income:

• Under $70,000: no co-pay
• $70,000–$79,999: 40% co-pay
• $80,000–$89,999: 60% co-pay
• $90,000+: not eligible

There is the potential for balance billing. This means that the dentist can charge more than CDCP coverage, in which case, you’re on the hook for the difference.

CDCP services include preventive care (cleaning and scaling, fluoride), exams, X-rays, fillings, root canals and dentures.