Coverage Gaps, Costs and 2026 Rules
What OHIP, MSP, RAMQ and other provincial health plans don't cover
The services Canadian provincial health plans leave to you, including drugs, dental, vision, therapy and ambulance fees, with the exceptions for children, seniors and low incomes.
Provincial health insurance plans in Canada pay for medically necessary visits to physicians and for hospital care, including tests, surgery, drugs given in hospital and a standard ward bed. For most working-age adults they do not pay for prescription drugs taken at home, routine dental care, eyeglasses or contact lenses, physiotherapy at a private clinic, massage therapy, chiropractors, psychologists, a private or semi-private room, most medical equipment, or the full cost of an ambulance. Several provinces cover some of these for children, seniors or people on low incomes, so the gap depends on your province, age and income. This guide maps the common gaps and how to check your own.
It belongs to the private health insurance in Canada overview. Amounts are illustrative unless a source is named.
What every provincial plan covers
Under the Canada Health Act, provinces must insure "medically necessary" hospital services and physician services for eligible residents, without user charges or extra billing. That core includes:
- Visits to family doctors and specialists for insured services
- Diagnostic tests ordered by a physician and done in hospital or an insured facility
- Hospital stays in a standard ward, nursing, meals and medication given during the stay
- Surgery and anaesthesia that are medically necessary
- Some dental surgery that must be done in hospital
Each plan has its own name: OHIP in Ontario, MSP in British Columbia, AHCIP in Alberta, the RAMQ health insurance plan in Quebec, and equivalent plans in the other provinces and territories.
The common gaps for adults aged 25 to 64
| Service | Typical provincial position | Who often gets public help |
|---|---|---|
| Prescription drugs at home | Not covered by the health plan itself | Seniors, young people (Ontario's OHIP+ for those 24 and under without a private plan), people with high costs relative to income, social assistance recipients |
| Dental check-ups and fillings | Not covered | Eligible uninsured residents through the federal Canadian Dental Care Plan; children and social assistance recipients through some provincial programs |
| Eye exams | Usually not covered for healthy adults | Children and seniors in many provinces; adults with certain medical conditions |
| Glasses and contact lenses | Not covered | Some social assistance programs |
| Physiotherapy | Hospital physio covered; private clinic physio usually not | Some provinces fund physio for seniors, young people or after a hospital stay |
| Psychologists, counsellors | Usually not covered outside hospital or public mental health programs | Public community mental health services, with waits |
| Massage, chiropractic, naturopathy | Not covered | Rarely, apart from limited programs |
| Ground ambulance | Partly covered; user fees vary widely by province | Often reduced or waived for seniors or social assistance |
| Private or semi-private room | Only the ward rate is covered | None |
| Hearing aids, mobility devices | Not covered by the health plan; some provinces have device programs | Ontario's Assistive Devices Program and similar programs in other provinces |
Treat the table as a starting point. For example, Ontario charges a $45 co-payment for a medically necessary ground ambulance trip for OHIP-insured people, while other provinces charge several hundred dollars; amounts are set by each province and may change, so confirm on your provincial site.
Worked example: one year of uninsured costs
A 35-year-old in Alberta with no group plan has, in an illustrative year:
- Two dental check-ups with cleaning at $250 each: $500
- An eye exam (not covered for adults in this case): $120
- Glasses: $350
- Eight physiotherapy sessions after a sports injury at $110: $880
- A three-month course of a brand-name prescription at $90 a fill: $270
Total: $2,120 paid out of pocket. Part of it may come back through the medical expense tax credit: with net income of $70,000, 3% is $2,100, so only $20 is above the threshold and the federal credit is worth under $3. The credit helps far more when expenses are high or income is low; see the medical expense tax credit worked example. Use the out-of-pocket estimate to build your own year.
Where public programs fill some gaps
- Drugs. Every province has a public drug program for some groups. Ontario has OHIP+ for people 24 and under who are not covered by a private plan, the Ontario Drug Benefit for 65 and over, and the Trillium Drug Program for high costs relative to income. British Columbia's Fair PharmaCare sets deductibles by family income. Quebec makes drug insurance compulsory for everyone. See provincial drug programs compared.
- Dental. The Canadian Dental Care Plan covers eligible residents with no access to private dental insurance and adjusted family net income under $90,000.
- Contraception and diabetes medication. Provinces that have signed pharmacare agreements with Ottawa are adding public coverage; see national pharmacare in 2026.
- Devices. Provincial assistive devices programs pay part of the cost of hearing aids, mobility aids and some supplies for eligible residents.
How to check your own coverage
- Go to your provincial ministry of health or health insurance plan site and search for "what is covered" or "insured services".
- Search separately for your province's drug program, eye care rules and ambulance fees.
- Note any age-based coverage that will start or stop for someone in your household in the next year, such as turning 25 in Ontario or 65 anywhere.
- Check your T4 or T4A slip box for dental coverage access before assuming you qualify for federal dental coverage.
- Only then decide whether a private plan is filling a real gap; group vs individual health insurance explains the options.
Mistakes to avoid
- Assuming hospital physiotherapy continues free after discharge. Outpatient physio often moves to a private clinic and is billed to you.
- Paying for an eye exam that is covered. Children's and seniors' exams are publicly funded in many provinces, so check before paying.
- Forgetting ambulance fees. They are rarely large but can reach hundreds of dollars in some provinces, and many group plans reimburse them.
- Buying a plan that duplicates a public program. A senior in Ontario already has public drug coverage; a private plan may still add value for dental and vision, but price that part alone.
Frequently asked questions
Does OHIP cover prescriptions?
OHIP itself does not cover drugs you take at home. Ontario's public drug programs, such as the Ontario Drug Benefit for people 65 and over, OHIP+ for people 24 and under without private coverage and the Trillium Drug Program, do cover eligible prescriptions.
Are blood tests and X-rays covered?
Tests ordered by a physician for an insured service are generally covered. Tests requested for non-medical reasons, such as some employment or insurance medicals, may be billed to you.
Is a sick note from a doctor covered?
Many uninsured services, such as sick notes, forms and missed-appointment fees, are billed by the clinic to the patient. Ask the clinic for its fee list.
Does my provincial plan cover me in another province?
Yes, for most insured services, under the portability principle, although physicians in some provinces may bill you directly and Quebec handles physician claims differently. See moving between provinces.
Sources
- Health Canada — Canada Health Act and federal health programs
- Government of Ontario — OHIP, ambulance co-payment and Ontario drug programs
- Government of British Columbia — MSP and Fair PharmaCare
- Government of Alberta — AHCIP and Alberta drug coverage
- Régie de l'assurance maladie du Québec — Quebec insured services
