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.} 

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 covers basic, essential medical services including: 

• 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 to fill in 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 will depend 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 plan: Economic, Classic, and Advanced. Each of these plans cover certain basic benefits, such as ambulance services and prescription drugs taken 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 offered by each plan. 

‍^{* Not a complete description of coverage.} 

Is private health insurance coverage worth it?

Private health coverage is worth it if your medical expenses aren’t adequately covered by your provincial health insurance plan. 

For many Canadians, a combination of public health insurance and an employer-sponsored group plan offers enough coverage to meet all their healthcare needs. But that’s not true for everyone. Canadians who may face significant coverage gaps without private health insurance include: 

• Retirees: Retirement can bring a host of ongoing medical expenses, including many not covered by provincial health plans, just as you’re removed from your previous employer’s group health insurance benefits plan. 
• Self-employed Canadians: If you don’t have access to supplemental health insurance through your work, you may have medical costs that your provincial plan won’t cover. 
• Individuals with more complex medical needs: Canadians with chronic health conditions may need more coverage than public health insurance policies offer. 

How to choose a health insurance plan

No two health insurance policies are the same. Before enrollment, take the time to choose a plan that best fits your needs and your budget. 

1. Take stock of your existing out-of-pocket healthcare costs. How much are you spending right now on routine check-ups, prescription drugs, and paramedical services not covered by provincial healthcare? Don’t forget to account for dental and vision care. 
2. Think about the future. Do you anticipate major expenses, like serious dental work or fertility care, down the line? 
3. Weigh your appetite for healthcare risk. Ideally, your health insurance plan will cover both routine care and major unexpected costs. But some plans may be lighter on coverage for big-ticket medical bills while still delivering valuable coverage for everyday expenses. Does that balance feel right to you, or do you need a more robust plan? 
4. Research deductibles, coinsurance, and exclusions. There’s a lot of variation between health plans, so make sure the fine print matches your needs. 

FAQs: What does health insurance cover? 

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