What Does Health Insurance Cover in Canada?

How does health insurance work in Canada?

The federal government of Canada funds and sets standards for public health insurance to cover medically necessary care for all eligible Canadians. 

But “universal” doesn’t mean that Canada’s public health insurance covers all the medical care Canadians use. That’s why employer-sponsored group health and dental insurance plans exist, as well as private health insurance policies to meet the needs of Canadians without access to group insurance. 

‍^{*Note that there will be some variance as to what’s covered and what isn’t, depending on the specific health insurance policy you have.} 

Key health insurance terms, explained

Health insurance plans in Canada, whether private or provincial, are often sprinkled with technical terms. The more familiar you are with these terms, the better equipped you’ll be to compare your options. As you explore different policies, expect to encounter the following:
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• Premium. The fee you pay every month to keep your private insurance plan active, which may be tax-deductible. 
• Deductible. The amount you pay out of pocket before your insurance kicks in. Not all plans have deductibles.
• Copay. A pre-set fee you pay each time you receive a service, regardless of its overall cost. For example: $5 per pharmacy refill.
• Coinsurance. A pre-set, shared cost split between you and the insurance company. For example, if your insurance provider covers 70% of a procedure, you pay the remaining 30%.
• Out-of-pocket costs. Any healthcare costs you pay upfront that may not be covered by an insurance plan, whether private, group or provincial. 
• Exclusions. Services or equipment not covered by an insurance plan, such as cosmetic or elective procedures. May also apply to pre-existing medical conditions that can disqualify you from certain insurance plans.
• Dependent. A dependent person whom you can add to your insurance plan, typically limited to children and spouses.
• Waiting period. A set time you may have to wait to access the full benefits of your insurance plan; 30 to 90 days is common. 
• Underwriting. An evaluation by an insurance company to determine your eligibility for a private insurance plan. 

What public healthcare covers

Canada’s universal healthcare, also known as Medicare, is funded by the federal government and administered by individual provinces and territories. If you’re registered for health insurance in your province or territory, your public health insurance covers basic, essential medical services including: 
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• Doctor’s visits
• Hospital stays
• Surgery (both inpatient and outpatient) 
• Diagnostic screenings (e.g., bloodwork and scans) 
• Medication prescribed in a hospital 
• Cancer care, including mental health services
• Some prescription drugs 
• Vaccinations

Public health coverage pays for vital medical care, but it isn’t comprehensive — and it can vary by province. The federal government sets general standards for health care coverage, but provinces determine eligibility as well as which health care services are (and aren’t) covered. 

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Public health coverage is full of carveouts

Aspects of medical care related to covered services that aren’t covered by your government health insurance plan. Example: if you’re in a car crash and need surgery, public healthcare may pay for the procedure and prescriptions you’re given in the hospital, but not for the ambulance needed to get there, the crutches you’ll need to go home, or ongoing physiotherapy needed to recover.

What workplace benefits cover

For many Canadians, group health insurance plans provided by employers help fill the gaps left by public health insurance. Workplace health benefits typically cover things that public insurance won’t cover, like: 

• Prescription drugs not prescribed in a hospital setting 
• Dental care
• Vision care and prescription eyewear 
• Ambulance services 
• Paramedical services such as chiropractic services, physiotherapy, or massage
• Critical illness coverage 
• Wellness care

What’s covered by your workplace benefits can vary depending on the company you work for, the provider they’ve chosen to partner with, and the plan you select. 

What private health insurance covers

If you don’t have access to an employer-sponsored group healthcare plan — or if your workplace benefits don’t cover all of your regular medical expenses — you may want to explore buying private health insurance, which can cover a wide range of costs. Private health insurance may cover the same services as group healthcare, like: 

• Prescription drugs
• Dental care
• Vision care
• Ambulance services
• Prescription eyeglasses
• Medical supplies
• Paramedical services (e.g., chiropractic, massage) 
• Major dental procedures
• In-home nursing
• Critical illness insurance

The exact coverage you receive under an individual health insurance policy depends on the plan you select and the health insurance company that delivers your coverage. 

Types of private health insurance coverage

Not all private health insurance plans offer the same coverage. You may have different benefits, deductibles, copays, and out-of-pocket expenses depending on the plan you select. 

For example, PolicyMe offers three types of health insurance plans: Economic, Classic, and Advanced. Each plan covers certain basic benefits, such as ambulance services and prescription drugs for pre-existing medical conditions. But the Classic and Advanced plans carry additional benefits and higher reimbursement levels than the Economic plan. 

The table below summarizes a few key differences in the benefits each plan offers. 

‍^{* Not a complete description of coverage.} 

Does private health insurance cover pre-existing conditions?

Yes, private health insurance can cover pre-existing conditions, but your options may be more limited. Private health insurance plans may involve a medical exam or questionnaire that make qualifying for coverage more challenging for those with pre-existing conditions. 

In general, plans are divided into two categories:

• Underwritten plan. These plans include medical questions and sometimes even medical exams. There are often exclusions that apply for certain pre-existing conditions, such as cancer, heart disease or diabetes, but premiums are typically lower for those who qualify.
• Guaranteed-issue plan. These plans waive medical questions in favour of accepting a wider range of applicants, including those with pre-existing conditions, but typically cost more than underwritten plans.
  

Guaranteed-issue plans, like PolicyMe’s Guaranteed Issue Economic plan, are ideal for those with chronic or ongoing health concerns who may not qualify for a traditionally underwritten plan. Depending on the plan, you may pay more for a guaranteed issue policy to help offset the risk.

If you have an ongoing health condition, check the policy’s definition of a pre-existing condition. Coverage for the same condition can vary among companies and plans.

Is private health insurance coverage worth it?

Private healthcare coverage may be worth it if your provincial plan, workplace plan or other coverage doesn’t fully cover your healthcare needs. It can help pay for expenses not covered by the government, including prescription drugs, paramedical services, and vision and dental care.

To determine whether private insurance is right for you and your family, learn more about private healthcare insurance. 

How to choose a health insurance plan

Choosing a health insurance plan involves reviewing your current out-of-pocket costs above your provincial or other coverage, as well as what costs you can realistically anticipate in the near future. This amount will help you understand what level of coverage you might need.

From there, compare costs, deductibles and exclusions to find the right plan for you.

FAQs: What does health insurance cover?