OHIP Covered Physiotherapy: Pros & Cons, Eligibility, and Availability

Like most clinics in Ontario, Toronto Physiotherapy made the decision not to participate in offering OHIP covered physiotherapy.

Even though we don’t offer it, we certainly field a lot of questions about it. Ontarians appear largely unclear about what OHIP funded physiotherapy is, where they can get it, and whether or not they are eligible; and government websites (such as the Ontario.ca webpage) don’t go far enough to explain it.

Critically, even if you are eligible to receive OHIP covered physiotherapy, should you?

OHIP funded physiotherapy takes a different form than what you might experience in many privately funded physiotherapy clinics – do you know what these differences are?

Here I will give you a more thorough overview of OHIP funded physiotherapy than you will find anywhere else.

Feel free to post a question or comment at the end of this article.

Who is eligible for OHIP covered physiotherapy?

This bit is relatively straightforward. To be eligible you must have a doctor or nurse practitioner’s prescription for OHIP covered physiotherapy AND be one of the following:

1. 65 years old or older.
2. 19 years old or younger.
3. Any age if you have recently spent a night in a hospital (as an inpatient) for an injury or condition that could benefit from physiotherapy.
4. A recipient of either the Ontario Works or the Ontario Disability social assistance programs.

What conditions or injuries qualify for OHIP covered physiotherapy?

In order to receive a prescription for OHIP covered physiotherapy your doctor or nurse practitioner will need to establish:

1. That you have an injury or condition that results in reduced mobility or inability to function in your daily life.
2. That your injury or condition would be expected to benefit from physiotherapy treatment.

Can I receive OHIP covered physiotherapy for arthritis or other chronic condition?

If you have a prescription for physiotherapy and meet the above eligibility criteria, then you can receive OHIP funded physiotherapy for chronic conditions, albeit with significant limitations:

OHIP will only cover physiotherapy targeted at resolving an acute episode or worsening of symptoms, and only if this worsening has reduced your mobility or ability to function in your daily life.

OHIP funded physiotherapy is not designed to address the long-term rehabilitation needs or ongoing management of chronic disease. This is an unfortunate consequence of how OHIP physiotherapy is funded – a topic we’ll cover further below.

How does OHIP covered physiotherapy work?

If you are eligible and have a prescription in hand, you are free to find an OHIP funded physiotherapy clinic and book in for treatment. OHIP funded physiotherapy clinics are private businesses that are under contract with the government of Ontario to offer this type of care. These businesses typically also provide private services for non-OHIP patients.

When you arrive at the clinic for your first visit you have now begun your “Episode of Care”. The clinic is required to provide you with as much physiotherapy treatment “as needed” to address your prescription. Sounds great! But as usual, the devil is in the details.

When are patients discharged from care?

Unfortunately, your “Episode of Care” will come to an end once any of the following loose criteria have been met:

1. Your physiotherapist believes you have achieved the rehabilitation goals set out by you and them.
2. Your physiotherapist determines that you should be able to achieve your rehabilitation goals on your own without further help from them.
3. Your physiotherapist determines that you should be able to achieve your rehabilitation goals using another means such as by participating in a community exercise, falls prevention, or other class.
4. Your physiotherapist determines that you are unlikely to see further improvement from additional physiotherapy.
5. You decide to stop coming for your own reasons.

Why would an OHIP clinic want to discharge you early? After all, the clinic is being paid to offer OHIP funded service, and has agreed to do so. Regrettably, a few years ago OHIP changed their clinic reimbursement practices. Instead of paying clinics per patient visit, clinics are now paid a small lump-sum amount for each “Episode of Care”, regardless of how many sessions the patient attends; so the clinic gets paid the same amount for treating a patient once as it does for treating a patient ten times. Worse still, the lump-sum amount they are paid per “Episode of Care” falls far below market-rates for physiotherapy (more on this below). The result: OHIP funded clinics have a very strong financial incentive to end your care as quickly as possible, and to provide care as cheaply as possible.

What is included in OHIP funded physiotherapy?

While you are attending the clinic, your physiotherapist will focus exclusively on the injury or condition outlined in your prescription. The clinic is not allowed to charge any additional fees related to the provision of physiotherapy within your “Episode of Care”, this includes any materials, equipment or supplies provided. However, they can recommend and sell you additional unrelated products or services, such as massage therapy.

I’ve already had OHIP funded physiotherapy this year, can I go again for another injury?

The number of “Episodes of Care” per year is not limited. For example, if you have an unrelated injury or condition, still meet the eligibility requirements set out above, and get another prescription for physiotherapy from your doctor or nurse practitioner, you can return for another “Episode of Care” at the same, or any other, OHIP clinic.

What if I stayed overnight in a hospital and have already received physiotherapy there? Can I still qualify to get physiotherapy at an OHIP funded clinic in my community?

Physiotherapy provided in the hospital setting is covered by OHIP and is typically of high-quality. Unfortunately, our hospitals are space and resource challenged, and so it is common to be discharged from the hospital in a state where you still require further physiotherapy care. In this case your discharging doctor or family doctor can offer you a prescription for additional physiotherapy at a private clinic in the community that offers OHIP covered physiotherapy.

What if I have a mobility restriction that necessitates receiving physiotherapy at home?

OHIP funded home-based physiotherapy is organized by Local Health Integration Networks (LHINs). You can find your local LHIN here, or learn more by calling 310-2222.

Pros of OHIP covered physiotherapy

If you are eligible and have a prescription:

1. It’s unlimited!* Get as much care as you need to address your prescribed need.
2. It’s free!* You don’t have to pay any fees to access this care.

*Sort of.

Cons of OHIP covered physiotherapy

1. It’s not exactly unlimited

And this isn’t just because eligibility is restricted. OHIP pays private businesses to offer this care, and the funding these clinics receive to do so is significantly below market rates. Whereas OHIP has negotiated to pay clinics $312 per patient “Episode of Care”, your motor vehicle accident insurance offers clinics more than ten times this much for an episode of care (up to $3500 for a minor injury case). Likewise, the Ontario Physiotherapy Association recommends that physiotherapists charge at least $150 per hour, and many clinics in Ontario charge in excess of this. So to receive unlimited treatment for Ontarians at a cost to the government of only $312?!? What a deal for the province of Ontario!

How can private business afford to provide care at such steeply discounted rates? After all, these private clinics must still pay their employees at market rates and pay their leases and other overhead as well. What’s going on here? It’s simple economics: these clinics are incentivized to provide care as inexpensively as possible and to end care as quickly as possible, and of course they have found ways to do so (more on this below), otherwise they would no longer be in business.

2. It’s not exactly free

Although you shouldn’t be paying anything out of pocket, you also don’t get the same type of physiotherapy as you could get if you paid out-of-pocket or paid using extended health insurance or automobile insurance. For private businesses to provide OHIP covered physiotherapy at such steeply discounted rates, they must reduce the cost of providing care. General cost-saving approaches such as foregoing an attractive looking clinical setting, or not having private treatment rooms will help, but in the end, they must look to their biggest cost-driver: their physiotherapists.

When it comes to human resources, popular cost-saving measures include limiting patient face-time with their physiotherapist by: double or triple booking patients; using support staff to provide care; having patients spend time alone doing exercises, leaving patients alone with a heat pack or other modality; providing care in a group-setting; narrowing the scope of care; and ending care as soon as possible. For example, having a physiotherapist assistant monitor three patients while they do exercises in a gym would constitute ‘physiotherapy’ under OHIP’s guidelines. But it would certainly not pass as physiotherapy in most non-OHIP funded physiotherapy clinics.

As you can see, OHIP covered physiotherapy is not exactly free, because it’s not exactly the type of physiotherapy that you can receive elsewhere. It’s true that you don’t have to pay anything out of pocket, but you are getting a low-cost model of physiotherapy care – and investing your time, effort, and energy to do so. With that said, this form of physiotherapy might be just what you need.

3. Fewer clinic options and longer wait lists

Not surprisingly, most clinics do not offer OHIP funded care. This limits the number of available clinic locations, and in some cases can result in long wait-lists. Clinics are allotted a specific number of “Episodes of Care” each year and are encouraged to spread them out over the year. Once they have used this allotment, OHIP clinics must wait until the next calendar year to get more.

Wait lists are further exacerbated by that fact that OHIP patients can be far less lucrative than non-OHIP patients attending these clinics, and are often unable to go elsewhere, which reduces their priority in the queue.

Should I go to an OHIP physiotherapy clinic?

If like most people you are financially constrained, then of course it’s worth it to give it a try!  It won’t cost you anything other than your time, effort and energy. If you end up feeling that you didn’t receive the right type of care, the most effective care, or enough care, you can always pay privately elsewhere either out of pocket or through private insurance.

Keep in mind that paying privately at a non-OHIP funded physiotherapy clinic doesn’t have to be as expensive as it might first appear.

For example, at our clinic initial assessments are one hour long and are entirely one-on-one with a Registered Physiotherapist for the whole duration. As a result, our “assessments” typically include time for hands-on treatment, education and home exercise prescription. There is also never any obligation to commit to additional visits. Your therapist will work with you to find a frequency of follow-up visits (if any are required) that best suits your physical and financial needs. Learn more about our model of physiotherapy care.

Finally, the more work you put into your rehabilitation, the sooner you will recover. In most cases, committing to your prescribed home exercise program will help speed your recovery and reduce the need for additional in-clinic care.

Physiotherapy also qualifies for the Medical Expense Tax Credit on your personal income tax return.

Where can I find an OHIP funded physiotherapy clinic?

The complete list of clinics that provide OHIP covered physiotherapy services can be found here.

Could my employer cover my costs instead?

Like many Ontarians, you may work for a small or medium-sized business (or own one yourself) that does not currently offer employee health benefits. Try asking for them. Speaking from experience, many small and medium-sized businesses will choose to provide their employees with health benefits if they feel that their employees would truly benefit from them, and would appreciate them as an employment perk.

You might think that small and medium-sized business can neither afford nor be able to mange an employee benefits plan, but there is a popular and accessible alternative to classic group health insurance. Inquire with your employer about setting up a flexible, easy to manage and inexpensive Health Spending Account like we use.