Looking to book a surgery but not sure if it’ll be covered by Ontario’s Health Insurance Plan (OHIP)? You’re not alone. The line between what makes a surgery cosmetic or medically necessary can feel unclear, and patients often have questions about what’s covered. Here’s a helpful resource to clarify which surgeries are typically covered by OHIP and how to navigate the coverage process.
What surgeries does OHIP generally cover?
OHIP generally covers surgeries deemed medically necessary, while cosmetic procedures are usually not covered. For example, a breast surgery that you’re electing to have to improve the shape and size of your breasts to make them look better wouldn’t be covered. But a breast reconstruction necessary after a mastectomy following a breast cancer diagnosis may be covered even though it’s essentially a cosmetic surgery. The key factor in determining coverage is whether the surgery is required for health reasons or purely for aesthetic improvement. This principle guides the coverage decisions for various types of surgeries.
Breast surgery
In the realm of breast surgery, OHIP fully covers breast reconstruction for patients who have undergone mastectomy or lumpectomy, typically due to cancer treatment. This coverage extends to future revisions and balancing procedures, so that patients have ongoing comprehensive care to ensure the right results. To access this coverage, a referral from a physician, such as an oncologist or surgeon, is required.
Breast reduction surgery
Breast reduction surgery may also be covered if it’s causing significant pain, discomfort, or physical medically related issues. However, it’s important to note that while the main procedure might be covered, any liposuction component would require out-of-pocket payment. We always combine liposuction with breast surgery so most reductions would include a non-OHIP covered component.
Gender affirming surgeries
Gender affirming surgeries, particularly top surgery involving breast removal, may be covered by OHIP with the appropriate referral. This reflects OHIP’s recognition of the medical necessity of certain procedures for transgender folks.
Tummy tucks and abdominoplasty
Abdominal surgeries present an interesting case in terms of OHIP coverage. While a standard tummy tuck (abdominoplasty) is generally not covered as it’s considered cosmetic, there are exceptions. The removal of excess skin (pannus) below the waist may be covered if it’s deemed medically necessary and creates pain or a notable obstacle to movement or healthy development, highlighting the nuanced approach OHIP takes to coverage decisions.
Rhinoplasty and nose surgeries
Nasal surgeries also straddle the line between cosmetic and medical necessity. While purely cosmetic rhinoplasty is not covered by OHIP, septorhinoplasty may be covered if it addresses breathing difficulties. In such cases, patients might find themselves in a situation where the functional aspects of the surgery are covered, but any cosmetic improvements would require out-of-pocket payment.
Skin Cancer and lesion removal
These surgeries are covered for both facial and non-facial areas. Benign lesion removal is not covered, and scar and lesion removal is covered when it’s deemed. medically necessary.
Hand and wrist surgeries
Many hand and wrist surgeries are covered by OHIP, including:
- Carpal Tunnel Release. Cubital Tunnel Release
- Trigger Finger Treatment
- Dupuytren’s Contracture Management
Looking for financing?
If you’re looking to help manage the cost of surgery and not wanting to break the bank, let us help you explore opportunities to balance your books. We offer financing options that help you break down the cost of surgery, making it affordable and accessible.
How to secure OHIP coverage
Securing OHIP coverage involves several steps.
- Patients typically need to obtain a referral from a relevant physician and then consult with a specialist who will assess the medical necessity of the procedure.
- For some surgeries, an OHIP application must be submitted, and approval can take several weeks.
- It’s crucial to understand that each case is evaluated individually, taking into account the patient’s medical history and previous treatments.
- For the most up-to-date information on OHIP coverage, it’s always best to consult with your healthcare provider or contact the Ontario Ministry of Health directly.
Curious about what’s covered? Book a consultation to plan your surgery.
Your true form awaits. Contact us today to book a consultation with our surgeons and we’ll walk you through your cosmetic and financing options. A consultation is the perfect place to ask questions, explore options, and start your new chapter.
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