OHIP pays for a maximum of 12 physiotherapy sessions a year for eligible patients at specially approved clinics throughout Ontario.
We help our clients figure out whether they qualify for OHIP-funded care. This support is currently limited to seniors, youth under 19, and some social assistance recipients.
Our Toronto-area clinics walk you through the process, ensuring you receive the expert support you need. In the following post, we dive into how the funding is structured and who can take advantage of it.
How Many Physio Sessions OHIP Covers
In the province of Ontario, physiotherapy funded through the Ontario Health Insurance Plan (OHIP) aims to improve access to recovery and rehabilitation for individuals who meet the criteria. The total number of sessions is highly individualized depending on the patient’s changing medical needs and improvement. It depends on the clinical judgment of their healthcare provider.
Coverage may differ wildly from patient to patient. It’s very important for patients living in Toronto and surrounding communities to know how these limits are set, particularly when budgeting for their health needs and long-term care.
1. The Concept: Episodes of Care
The Idea – Episodes of Care OHIP coverage is based around an idea known as an “episode of care.” Within this time frame, one patient would be receiving physiotherapy to rectify one health concern. This might be rehabilitation from a hip replacement or treatment for an arthritis episode.
Each episode starts with a new referral. It ends once we reach the targeted goal, or an equally impactful alternative is achieved. Measuring these episodes allows us and our patients to establish realistic expectations and begin planning for future steps.
2. What Defines an “Episode”?
An episode begins when a physician refers a patient to physiotherapy for a given complaint. The process is complete when the problem has been addressed. It ends when the individual achieves their objective or has a significant change in their condition.
A person might have one episode defined for a knee injury and then a different one defined later for a shoulder issue. We explain when a new episode starts. This makes it easy and seamless for our patients to continue the process on their end.
3. Typical Session Limits Per Episode
Unlike other rehab disciplines, there is no hard, province-wide limit on sessions per episode under OHIP. Patients usually get 6-12 sessions per episode. While this number may be higher or lower based on the patient’s unique condition and needs, rehab post-surgery could require more sessions, while treatment for a mild sprain would require less.
We always prepare patients for their first appointment so they know what to expect.
4. Getting a Doctor’s Referral is Key
Getting a doctor’s referral is key. A doctor’s referral is generally required to begin OHIP-covered physiotherapy. This written referral should detail the medical reason for treatment, which can assist in deciding how many sessions are needed.
Patients may receive referrals from family physicians, specialists, or following a hospital discharge. We take all of our clients through this step to maximize coverage when the time comes.
5. Specific Conditions Often Covered
Who does OHIP cover physiotherapy for? It covers youth 19 and under, anyone who has been admitted overnight to a hospital, and individuals supported by ODSP or Ontario Works. Some common examples are postoperative recovery, fracture recovery, or neurological recovery such as stroke.
The details of the condition will inform the treatment plan and number of sessions.
6. How Coverage is Tracked
We log each session and stay current on our documentation. This will ensure that patients and their physicians can readily monitor how many visits patients have utilized. OHIP uses this data to prevent overspending on covered services.
This is a good approach because it makes sure patients don’t lose access to care if they require more assistance down the line.
7. Recent Policy Updates You Should Know
Recent policy changes allow people who do not have an OHIP card but are receiving ODSP or Ontario Works to still be eligible for coverage. New regulations give more options in how referrals can be made.
Though still focusing on clinical need above a predefined number of visits, the system allows for flexibility. Keeping abreast of these changes allows us to better serve our patients in maximizing every possible dollar of funding.
8. Exceptions: When More Sessions Might Apply
Sometimes, additional sessions are necessary – for example, following a set-back, or if progress requires more time due to the presence of other health conditions. These exceptions are not common and often require additional documentation and specific medical rationale.
We strongly advocate for open dialogue among patients, physicians, and our staff. This even helps everyone continue to be active participants in their path to recovery.
Accessing Your OHIP Physio Benefit
Getting OHIP-funded physiotherapy in Toronto and the rest of the GTA takes a bit of preparation. After you understand what to expect, it’s pretty easy. Unfortunately, we hear from so many individuals who are intimidated and don’t know how to get started. Then they ask all the questions… Who’s eligible? What’s the process?
Here’s our quick guide to get the most from your OHIP physio benefit. This guide is for you, no matter if you live in North York, Mississauga, Etobicoke, Bolton, Brampton or anywhere else in Ontario.
Finding OHIP-Funded Clinics
- To find Community Physiotherapy Clinics, use the Health811 Ontario website or the official Ontario provincial government site.
- Request your family doctor or nurse for a list of clinics in your community that accept OHIP.
- When in doubt, call clinics up directly and ask if they’re funded for OHIP physio.
- Check with community centers and hospitals for referral lists.
- Find clinics that advertise “OHIP-covered” or “Community Physiotherapy Clinic” status.
Just be sure to confirm that the clinic you’re looking at is OHIP-covered. Not every private clinic will be able to bill OHIP, or remain eligible long-term.
Begin with exploring your community, including the local public health unit. They can assist you in finding a clinic if you require additional support.
The Referral and Assessment Process
First, you’ll need a referral from your doctor or nurse practitioner. This step is required for most people, especially if you’re over 65, recently out of hospital, on ODSP, or on Ontario Works.
After you secure your referral, the clinic will schedule an assessment to review your needs. The healthcare provider plays a key role here – they help explain your situation and send the proper paperwork.
Quick assessments lead to more timely care, so don’t wait to book after you get your referral.
What Documentation You Need
- Valid Ontario health card
- Doctor’s referral letter
- Discharge summaries (if recently hospitalized)
- Medical history documents
- Proof of program enrollment (ODSP or Ontario Works, if applicable)
A valid health card and referral letter are key – they’re your golden ticket to funded care. To better prepare yourself, we recommend collecting all documents beforehand and having copies of all paperwork ready for your first appointment.
Navigating Wait Times: A Reality Check
In some parts of Ontario, such as Toronto, wait times for OHIP-funded physio can be weeks or even months. Most importantly, it’s crucial to establish expectations right from the start.
Inquire at clinics about their average wait times and whether they have a cancellation list. Don’t let go of that connection – follow up, recheck and secure your place if you have not received any further news post-referral.
Your First Appointment: What to Expect
At your first visit, you’ll meet your physiotherapist, who will do a full assessment. We’ll ask about your medical history, any recent hospital stays, and your treatment goals.
This is your chance to share concerns and talk about what you hope to achieve. From here, we’ll build a treatment plan that fits your needs and matches OHIP coverage rules.
What OHIP Physiotherapy Includes (and Excludes)
Knowing what is included and excluded under OHIP-funded physiotherapy will allow us to help our patients make informed decisions about their care. In Toronto, and Ontario as a whole, OHIP coverage is determined by rigid guidelines. These regulations govern eligibility for services, reimbursement for services provided, and what it excludes from their plan.
We see many patients who are unsure about what to expect, so we want to make these details as clear as possible.
Covered Services Within Your Sessions
OHIP physiotherapy covers a select group of services for those who qualify. The main services paid for include an initial assessment, hands-on therapy, supervised exercises, and some education about managing symptoms.
These sessions are focused on helping people who have lost function after an illness, injury, or surgery. Most of our patients use these services after an overnight hospital stay, joint replacement, or a flare-up of a chronic condition.
Coverage is provided for kids under 19, adults over 65, and people on Ontario Works or the Ontario Disability Support Program. To get these benefits, you’ll need a doctor’s referral and a valid Ontario health card, except if you’re on social assistance.
These services take place in approved clinics or, for some seniors, right at home. We always stress how important it is to ask what is and isn’t included in your plan before you start. Knowing this helps you avoid surprises.
Services Generally Not Covered by OHIP
In fact, a number of advanced or specialty treatments are not included in OHIP’s payment structure. This means, for instance, that custom orthotics, acupuncture, sports medicine consults, and laser therapy are not funded.
Massage therapy, some equipment, and additional classes aren’t covered either. Patients who need a more thorough plan for recovery have to pay for these extra services themselves.
Or else, they can pay forward with private insurance. This can be a lot so we encourage everyone to discuss your complete needs at the outset. Knowing what your extended health benefits will cover can help fill in these gaps.
Understanding Potential Extra Costs
Additional costs can sometimes be unexpected if you don’t inquire about them beforehand. Other clinics may charge a fee for missed appointments, use of special equipment, or treatment sessions over and above what OHIP pays.
That’s why we feel it is better to have an understanding of the costs upfront so you can better plan for your care. If cost is an issue for you, inquire about any payment plan or assistance programs they might offer.
Most clinics, including ours, are happy to discuss options with you first.
When OHIP Coverage Isn’t Enough
Whether you live in Toronto or the GTA, like many of us, you rely on OHIP coverage for physiotherapy. The reality is that its coverage often fails to deliver. The lump-sum amount paid per “Episode of Care” is far less than what private clinics cost, and not everyone is eligible.
We see in our day-to-day experience the holes this leaves for individuals who need additional sessions or more specialized care. This is particularly urgent for people post-surgery, with chronic pain and long-term injuries. For many, this means incurring out-of-pocket costs or figuring out how to pay for care through other funding streams to receive the necessary post-operative care and rehabilitation.
Reaching Your OHIP Session Limit
Once we hit the OHIP session limit, treatment frequently ends before a full recovery can be made. It can mean some patients are no longer well enough when they need it, but coverage has expired. From here, our work shifts to guiding patients through the next steps.
Private pay, extended health benefits, or workplace/community funding are possible options. Keep in touch with your physiotherapist. They will talk you through your options and assist with prioritizing treatment if you are unable to cover all costs.
Exploring Private Physiotherapy Options
When OHIP coverage doesn’t go quite far enough, private physiotherapy is available. Here are some things to think about:
- Cost per session and number needed
- Availability of specialized treatments or equipment
- Clinic location and accessibility
- Wait times at private clinics versus OHIP-funded clinics
- Qualifications and experience of staff
Private care can provide quicker access, longer sessions with your physiotherapist, and cutting-edge treatments, but it isn’t affordable. Without private insurance, sessions can cost anywhere from $75-$150 per session.
We would never recommend a patient commit to an expensive treatment without first weighing the costs and benefits. Furthermore, we recommend them to inquire if they offer partial session packages or payment plans.
Using Extended Health Benefits Wisely
If you’re one of the 60% of Ontarians with private insurance, you’ll want to make sure you’re using your coverage wisely. Most extended health benefit plans provide a $300-$500 annual allotment of physiotherapy. Yet, they frequently have stipulations attached, such as restrictions on clinics you’re able to go to.
As always, we recommend reading your policy to be aware of limits, exclusions, and pre-authorization requirements. Adjust your strategy as soon as possible to prevent unexpected issues down the road. In this manner, you get to really get the most out of your benefits.
Workplace Injuries (WSIB) vs OHIP
If you sustained your injury at your place of employment, WSIB may pay for your physiotherapy. WSIB coverage usually provides greater extent benefits compared to OHIP. It usually covers a limited number of sessions, tailored to your injury.
The process is similar to OHIP with first reporting your injury, receiving a claim number, and being treated at a WSIB-approved clinic. Not everyone is eligible, and be sure to check WSIB’s guidance. For the few who qualify, this support fills the gap created by OHIP’s limited coverage.
Other Funding Avenues to Consider
Other funding options include:
- Community programs for low-income residents
- Grants from local charities or patient groups
- Financial assistance programs at some clinics
- Support from local health organizations
Nearly all of these programs specifically aim to serve residents in Toronto or the GTA. They fill the gap for people not covered by OHIP or who need more care. Inquiring with your physiotherapist or clinic about these resources can unlock assistance you didn’t realize was available.
Making the Most of Your Covered Sessions
How to make the most of OHIP-covered physiotherapy in Toronto and beyond. Just going to your appointment isn’t enough. Covered sessions are virtually unlimited for those who qualify. This extends to those with a valid prescription, as well as individuals who are under the age of 19 or over 65 – but wait!
Under this model, seen in the example illustrated below, clinics are reimbursed a lump sum for each “Episode of Care,” significantly influencing how many sessions you receive. Collaborating in tandem with your physiotherapist is key. With this new partnership, you can maximize every visit and reach your rehab goals sooner with no additional out-of-pocket expense.
Establishing clear goals keeps both you and your physio team focused on what needs to be accomplished. When you know what you want – maybe walking pain-free, being able to lift a grandchild, or getting back to sports – you and your therapist can focus every session on what matters.
Though it’s unusual to receive more than one referral in a calendar year, at times you can receive two or three. That initial “Episode of Care” is important for nearly everyone. You can realize some pretty tremendous wins by getting ahead and involved from the scratch.
Communicate Clearly With Your Physio
Honest communication with your physio goes a long way. Tell us what you’re struggling with and what’s going well. By letting your physio know what is bothering you, the plan can be modified accordingly to meet your needs.
Don’t leave this until the final covered session. Ask questions – such as the purpose of an exercise, or what the next step should be. Your feedback helps us to understand what’s working and what isn’t, so every appointment gets you nearer to your objectives.
Follow Your Home Exercise Plan
The work doesn’t end there – not by a long shot. We have found that the most optimal outcomes occur when patients are compliant with their home exercise program. These plans are designed to help you stay on track in between visits.
Even when you start to feel better, continue with your prescribed stretches or strength exercises. Tracking your progress – writing down what you do or using an app – helps us know if things are moving in the right direction.
Understand Your Discharge Plan
Understanding your discharge plan is crucial. Understanding what to expect when your “Episode of Care” is over is as important as the treatment you received. We’ll talk you through what to do next, whether it’s more exercises at home, a follow-up with your doctor, or tips to keep pain away.
If something doesn’t make sense, inquire. A thoughtful discharge plan will set you up to continue to improve long after your covered OHIP sessions have ended.
Avoid Surprise Bills: Know Your Costs
Knowing what physiotherapy will cost you is essential to better budgeting and a worry-free recovery process. In Toronto and the GTA, OHIP covers a set number of physiotherapy visits annually for patients who qualify. Consumers are often surprised by the out-of-pocket maximums, copays, and other costs of these services.
We are doing our part in ensuring our patients are aware of their costs upfront, before any course of treatment begins. We hope people have the information they need, so they can spend their time and energy on recovery – not stressing about surprise bills. Before we jump into the nitty-gritty, let’s quickly run through the T-R-U-C-K steps that will save you from surprise bills.
Confirming OHIP Coverage Before Treatment
As we recently mentioned, it’s very important to confirm your OHIP coverage prior to your initial treatment. Most of our clients assume that OHIP pays for every appointment. It’s easy to overlook that the coverage is only for certain cases and a capped number of sessions.
For instance, seniors aged 65 or older, youth under the age of 19, and those recently discharged from a hospital might be eligible. Otherwise, we recommend calling the clinic directly and inquiring about your eligibility. Request written verification, or note down the details of your conversations with the clinic or provider.
This written documentation will be useful if any disputes arise down the line or if your specific insurance plan requires documentation.
Questions to Ask the Clinic
These are questions you should absolutely ask upfront and in plain terms before undergoing any sort of treatment. We recommend asking:
- How many sessions does OHIP cover for my situation?
- Will I need a doctor’s referral for coverage?
- Are there additional charges or costs outside of OHIP coverage?
- What if I need additional sessions beyond what OHIP covers?
- What are my options if coverage runs out?
- Are you able to walk me through your clinic’s billing process and timeline?
Having this information in advance helps you plan your budget and steer clear of surprise bills. Other clinics may bill unexpected costs such as specialized equipment or higher level procedures. Inquire about all potential charges and obtain all information in writing.
Understanding Clinic Billing Practices
Billing may seem straightforward, but there’s usually more than meets the eye. We want everyone to understand that we support transparency of all costs. Billing practices vary in Toronto clinics – some do direct insurance billing, some require payment up-front.
Be sure to verify that your bill reflects what you consented to. Check every claim for correctness, and don’t be timid about confronting them on any fees you’re confused about. Engage with your insurance provider about their procedures regarding claims, copay, and annual limits.
For instance, copayments typically vary between 10% and 30%. Understanding clinic billing practices allows you to better anticipate the cost in your budget and avoid being blindsided when the bill arrives.
