We get asked all the time at our Toronto clinic if OHIP covers plastic surgery because patients want to know how much they will have to pay before they go ahead. We help patients with these questions all the time at Beber Plastic Surgery. The short answer is OHIP covers some plastic surgery but not others. The difference is whether the procedure is medically necessary or just for looks.
The Ontario Health Insurance Plan (OHIP) covers plastic surgery that is medically necessary or reconstructive. These procedures are done to fix abnormalities, restore function or fix damage caused by injury or disease, not just to make someone look better. The government knows some plastic surgery procedures are necessary to fix real medical conditions that harm health and quality of life and these procedures are covered.
Breast reconstruction after a mastectomy to treat cancer is one of the most common plastic surgery procedures OHIP covers. If you had a breast removed because of cancer, OHIP will cover the operation to replace it, with implants or by moving tissue from another part of your body. This coverage also includes procedures on the other breast to make it even, since having a balanced look is part of full reconstruction. Many patients don’t know how much this coverage is, so they are happy to hear their reconstruction options are covered. OHIP also covers skin cancer removal and repair. When dermatologists or plastic surgeons remove skin malignancies, especially from visible areas like the face, reconstructive surgery to close the wound and reduce scarring is covered. OHIP knows these surgeries are necessary for the health of patients because they make them look normal again after medically necessary cancer treatment.
OHIP usually covers birth defects. Children born with cleft lips or palates get covered surgery to fix them because these problems can make it hard to eat, talk and grow facially. In the same way, surgery is usually covered for other birth abnormalities that affect how a person looks and functions.
Blepharoplasty, or eyelid surgery, may be covered by OHIP if your eyelids are sagging so far that it’s hard to see. You might be able to get surgery covered if the skin on your upper eyelid falls down so low that it restricts your vision and makes things like driving or reading hard. OHIP needs proof of eyesight loss which usually means an ophthalmologist has to do visual field tests. Eyelid surgery that’s just to make the eyes look better and not to fix functional vision problems is not covered.
OHIP sometimes covers breast reduction but the rules are very strict and have changed over time. In the past, OHIP would cover breast reduction for people who had physical complaints like chronic back pain, neck pain or shoulder grooves from bra straps when they needed to have a certain amount of tissue removed. But OHIP’s new criteria are stricter and many breast reduction surgeries that would have been covered in the past are no longer eligible. No matter what kind of coverage a patient has, we help them understand the current eligibility criteria and explore their options.
After losing a lot of weight, getting body shaping surgery can be hard to cover. Many people who have lost 100 pounds or more have extra skin that hangs down and causes medical problems like rashes, infections and difficulty moving around. Technically, OHIP will cover the removal of this extra skin if it causes demonstrable medical problems. But getting approval can be tough. Before OHIP would pay for treatment, patients often need a lot of paperwork about skin problems and attempts at conservative treatment. OHIP doesn’t cover cosmetic procedures. This means treatments done for cosmetic reasons like breast augmentation, facelifts, rhinoplasty, liposuction and tummy tucks. OHIP doesn’t see these as medical necessities even if you think they would greatly improve your quality of life and self-esteem. Patients who want these procedures have to pay for everything themselves.
Getting OHIP approval for covered procedures requires paperwork and long wait times. Your surgeon has to send in a lot of information about why the procedure is medically necessary. This usually includes pictures, medical documents showing symptoms and results of diagnostic testing. This is reviewed by OHIP and they decide if the procedure meets their coverage criteria. Even if you think your condition clearly requires covered surgery, you may not get approved.
There are long wait times for plastic surgery in Toronto that is covered by OHIP. Because these procedures are paid for by the government, there’s usually more demand than there is operating room time. Patients who have been approved for covered breast reconstruction or other procedures may have to wait months or even more than a year for their surgery. Many people are frustrated with this since they’re ready to go but have to wait for their turn in the public system.
Some patients pay for procedures that might be covered by OHIP out of their own pocket because they don’t want to wait or aren’t sure if they’ll be approved. When you pay for surgery out of your own pocket, you can schedule it when it’s convenient for you without having to wait for the government to approve it or for an operating room to be free. We talk to patients about public and private options so they can choose what’s best for them.
When necessary, Beber Plastic Surgery helps patients understand their insurance options and the process for getting OHIP approval. We discuss private payment options and financing arrangements that make surgery more accessible for procedures that aren’t likely to be covered. We believe everyone should have accurate information about prices and coverage so they can plan for their care. It’s important to know that OHIP may not cover all of the costs associated with a procedure, even if they do cover the surgeon’s fee. For example, if you have surgery in a hospital, the surgeon’s fee might be covered, as well as the cost of the facility and some supplies. But if you choose a private surgical centre, you will have to pay for those facility fees yourself. We make sure to clarify all possible fees during the consultation so you know what you’re getting into financially. Breast Revisions correct or refine the results of previous breast surgeries for optimal outcomes.
Extended health insurance through employers sometimes covers parts of cosmetic procedures that OHIP doesn’t, but this is not common. Some insurance policies will cover a small amount of cosmetic surgery, usually a few hundred dollars instead of a lot of coverage. Before you think OHIP is your only option for coverage, we recommend checking with your insurance company to see what other benefits are available.
It’s not always easy to tell the difference between medically necessary and cosmetic procedures. There may be both practical and aesthetic benefits to a procedure, which makes it hard to know if it’s covered. Based on our years of experience working with these systems in Toronto, we help patients understand how OHIP sees their case. Dr. Brett Beber, MD, FRCS, is a highly regarded plastic surgeon in Toronto known for his dedication to achieving natural, refined results through advanced surgical techniques and personalized patient care.
Disclaimer: The information provided by Beber Plastic Surgery is intended for general informational purposes only and should not be taken as medical advice, diagnosis, or a guaranteed cost estimate. Surgical pricing and treatment outcomes vary for each individual based on anatomy, procedure complexity, surgeon expertise, and other medical or facility-related factors.
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