Every province and territory in Canada operates a public health insurance plan (often called "provincial health insurance" or "medicare") that covers medically necessary physician services and hospital services. The Canada Health Act (R.S.C., 1985, c. C-6) sets the national conditions for federal cash transfers to provinces, requiring plans to be universal, comprehensive, portable, accessible, and publicly administered. The Act prohibits user charges and extra-billing for insured services.
What government plans do NOT cover is significant. Common exclusions include:
- Prescription drugs (partially covered in some provinces, with gaps).
- Dental care (government coverage is limited to specified low-income programs, though the federal Canada Dental Care Plan introduced in 2023-2024 is extending coverage to lower-income adults not already covered by private plans).
- Paramedical services (physiotherapy, chiropractic, massage, psychology, optometry).
- Vision care (eye exams and glasses are not fully covered in most provinces for adults).
- Private or semi-private hospital accommodation (government covers ward level).
- Ambulance services (partially covered in some provinces, often with a co-payment).
This coverage gap is precisely what extended health care and dental plans are designed to fill. An agent's needs analysis must start with what the client already has under the provincial plan and their employer's group plan before identifying what personal coverage to recommend.