The information below is taken form the Federal & Provincial websites listed at the base of this section
Medicare
- Medicare is Canada’s publicly funded health care system. National plan for 13 provinces & territories
- Reasonable access to medically necessary hospital and physician services without paying out-of-pocket.
- Roles & responsibilities for health care services are shared between provincial/territorial governments and the federal government.
- provincial and territorial governments are responsible for the management, organization and delivery of health care services for their residents. (For Ontario – Ontario Health Insurance Plan)
The federal government is responsible for:
- setting & administering national standards for the health care system through the Canada Health Act
- providing funding support for provincial and territorial health care services
- supporting the delivery for health care services to specific groups
- providing other health-related functions
Canada Health Act
Provincial and territorial health care insurance plans must meet the standards described in the Canada Health Act. This is necessary to get their full payment under the Canada Health Transfer.
These standards include:
- Public administrationThe provincial and territorial plans must be administered and operated on a nonprofit basis by a public authority.
- Comprehensiveness The provincial and territorial plans must insure all medically necessary services provided by hospitals, physicians, and dentists (when the service is performed in a hospital). Medically necessary services are not defined in the Canada Health Act. The provincial and territorial health care insurance plans consult with their respective physician colleges or groups. Together, they decide which services are medically necessary for health care insurance purposes If a service is considered medically necessary, the full cost must be covered by the public health care insurance plahospitals
- Universality provincial and territorial plans must cover all residents.
- Portability The provincial and territorial plans must cover all residents when they travel within Canada. Limited coverage is also required for travel outside the country. When a resident moves to another province, they can continue to use their original health care insurance card for 3 months. This gives them enough time to register for the new plan and receive their new health insurance card.
- Accessibility The provincial and territorial plans must provide all residents reasonable access to medically necessary services. Access must be based on medical need and not the ability to pay.
Accessing Healthcare in Canada
Canadians most often turn to primary health care services (often called family doctor) as their first point of
Primary health care:
- delivers first-contact health care services
- coordinates patients’ health care services to support:
- continuity of care, which means receiving high quality care from diagnosis to recovery
- ease of movement across the health care system when more specialized services are needed from specialists or in hospital
Supplemental Coverage
Provinces and territories also provide supplemental coverage to certain groups of people, such as:
- seniors
- children
- social assistance recipients
This helps pay for health care services that are not generally covered under the publicly funded health care system. These can include visioncare, prescription drugs etc.
Those who do not qualify for supplementary benefits under government plans pay for these services through:
- out-of-pocket payments
- private health insurance plans
OHIP (The Ontario Health Insurance Plan)
OHIP does not cover some specialized, non-routine tests.OHIP will only cover them if patient meets certain eligibility criteria & a particular health care ordered the test. Examples include:
- Prostate-specific antigen (PSA) is covered by OHIP if either of the following apply to :
-
- Patient has been diagnosed with prostate cancer and are receiving treatment or following up after receiving treatment for the disease
- a healthcare provider suspects prostate cancer because of history and/or the results of patient physical examination (including digital rectal examination)
- For all other scenarios, you will need to pay for PSA.
2. Aspartate aminotransferase test (AST) is covered by OHIP if ordered by a physician who specializes in liver diseases.
3. 25-hydroxy vitamin D test is covered by OHIP if you have any of the following conditions:
-
- osteoporosis
- rickets
- osteopenia
- malabsorption syndromes
- renal disease
- drugs that affect vitamin D metabolism
- For all other scenarios, you will need to pay for a vitamin D test.
References:
-
- Canada’s Healthcare System link
- Ontario Health page including OHIP (Ontario Healthcare Plan) link
- What OHIP covers link
