What individual health and dental coverage is for
OHIP covers medically necessary physician and hospital care in Ontario. It does not extend to most prescription drugs for working-age adults, routine dental care, eyewear, or the practitioners people actually use when something hurts.
Employees typically have some of this covered through work. Self-employed Ontarians who want it generally buy an individual plan, and the benefits, limits and conditions depend entirely on the plan chosen.
Prescriptions
Drug coverage is often the reason people start looking. Plans vary in how they handle it, and the differences matter more than the headline percentage.
- Whether a formulary limits which drugs are eligible
- An annual maximum on drug reimbursement
- A per-prescription deductible or dispensing fee cap
- How ongoing maintenance medications are treated
- Whether pre-existing conditions are excluded under the plan applied for
Dental
Dental benefits are commonly split into categories. Preventive and basic services such as cleanings, exams and fillings are often reimbursed at a higher percentage than major services such as crowns or bridges, and orthodontics is frequently excluded or capped separately.
Waiting periods on dental categories are common in individual plans, especially for major work. Not every plan applies them, and the length differs.
Vision
Vision benefits are usually expressed as a fixed dollar amount over a set period, for example a defined amount toward glasses or contact lenses every two years, sometimes with an eye exam allowance. Amounts and frequency vary considerably between plans.
Paramedical services
Paramedical coverage applies to licensed practitioners outside of physician care. Plans often set a per-practitioner or combined annual maximum, and the list of eligible practitioners is not identical from one insurer to another.
- Physiotherapy, chiropractic and massage therapy
- Psychology and other mental health practitioners, where included
- Naturopathy, acupuncture, podiatry and similar services in some plans
- Whether a physician referral is required for reimbursement
Deductibles, coinsurance, maximums and waiting periods
These four settings, more than the premium alone, decide how a plan behaves in a year when you actually need it.
| Term | What it means | Why it changes the value |
|---|---|---|
| Deductible | Amount you pay before reimbursement starts | A low premium with a high deductible can reimburse very little in a light year |
| Coinsurance | The percentage reimbursed after the deductible | 80 percent versus 50 percent on the same expense is a large practical difference |
| Category maximum | Cap per year or per lifetime on a benefit | Determines the ceiling on what the plan can ever pay for that category |
| Waiting period | Time before certain benefits become claimable | Most often applies to dental or major services, where present |
Why individual plan benefits vary
There is no standard individual health plan in Ontario. Insurers build different tiers, apply different medical questions, and set their own formularies, maximums and exclusions. Two plans at a similar monthly cost can cover very different things.
Nothing here should be read as a statement that every plan includes the same benefits, or that a particular expense will be reimbursed. The plan contract and benefit schedule govern.
Relationship to disability insurance and small-business benefits
A health and dental plan reimburses expenses. It does not replace income. For a self-employed person, an illness or injury that stops work is a separate exposure, and individual disability insurance is the product designed for it.
If your business is incorporated or has employees, a small-business benefits arrangement may be an alternative or a complement to an individual plan. Which route makes sense depends on your structure, and any accounting or tax treatment should be confirmed with your accountant.
Honest limits on what this page can tell you
Eligibility, benefits, exclusions and pricing are determined by the insurer and the plan issued. This page is general information about how these plans are typically constructed in Ontario, not advice, a quote, or an assurance of coverage.
Common questions
What does private health insurance cover that OHIP does not?
OHIP covers medically necessary physician and hospital services in Ontario. Individual health plans are generally designed around things OHIP does not pay for, which commonly include prescription drugs, dental care, vision, and paramedical practitioners. What any specific plan includes is set out in that plan's contract, and benefits are not the same across plans.
Is there a waiting period before I can claim?
Some plans apply a waiting period to certain categories, and dental or major services are the most common example. Others begin at the effective date. Because this varies by insurer and plan design, the plan documents are the only reliable source.
What is the difference between a deductible, coinsurance and a maximum?
A deductible is the amount you pay before the plan begins reimbursing. Coinsurance is the percentage the plan reimburses after that, for example 80 percent. A maximum caps how much the plan will pay for a category, often per year or per lifetime. All three interact, which is why two plans with similar premiums can behave very differently.
Can I be declined for an individual health plan?
Some individual plans are medically underwritten and can be declined, rated or issued with exclusions. Others are designed with limited or no medical questions but usually pair that with lower maximums or reduced benefits. Eligibility and terms are determined by the insurer.
Should I set up a plan through my business instead?
If you have a corporation or employees, a small-business benefits arrangement may be worth reviewing alongside an individual plan. The right structure depends on your business setup and should be reviewed with your accountant. We do not provide tax or accounting advice.
Does a health plan replace disability insurance?
No. Health and dental plans reimburse eligible expenses. Disability insurance is designed to replace income if illness or injury prevents you from working. They address different problems and are underwritten separately.
Keep reading
How individual health and dental plans in Ontario are structured.
Small business health benefitsOptions when your business has employees or is incorporated.
Disability insuranceIncome protection when illness or injury stops your work.
Critical illness insuranceA lump-sum benefit on diagnosis of a covered condition.
Life insurance for self-employedIncome replacement and debt coverage without a group plan.
Talk to a licensed brokerCompare plan structures with an Ontario health insurance broker.
Written and reviewed by Mathew Cordeiro, a licensed life and health insurance broker serving Ontario through Bluebird Assurance. This page is general information only, not financial or insurance advice. Coverage, features, eligibility and pricing vary by insurer and are subject to underwriting and policy terms.