Changes to OHIP Coverage for Eye Care Services
Effective November 1, 2004
Routine eye examinations provided by either an optometrist or physician, for patients aged 20 to 64 are no longer covered by OHIP. These individuals pay for this service or have the cost of examinations covered by private insurance.
Eye Care Services Covered
Changes do not affect seniors or those under age 20. People 65 years and older and under 20 will continue to have OHIP coverage for an eye examination once every 12 months.
Changes do not affect ophthalmology services for patients of any age with medical conditions or diseases affecting the eyes.
Persons receiving assistance under the Ontario Disability Support Program, Ontario Works or the Family Benefits Program continue to receive coverage for routine eye examinations once every two years.
Increased Coverage for People with Medical Conditions
OHIP is increasing coverage for patients aged 20 to 64 years with medical conditions affecting the eye. Patients can receive a regular eye examination once every 12 months. Prior to November 1, 2004, eye examinations were covered once every two years.
Patients with any of the following conditions can go directly to their optometrist or physician to receive an OHIP insured eye examination: diabetes mellitus, glaucoma, cataract, retinal disease, amblyopia, visual field defects, corneal disease, strabismus.
Patients aged 20 to 64 who have conditions not listed above may also be covered for a regular eye examination. They should discuss this with their primary health care provider.
Frequently Asked Questions
When do these changes take effect?
Routine eye examinations for people 20 to 64 years old provided by optometrists and physicians are no longer covered as of November 1, 2004. There is new OHIP coverage to ensure patients aged 20 to 64 years with medical conditions affecting the eye can continue to receive regular eye examinations.
Are persons between 20 and 64 exempt from paying for eye examinations if they have certain specific medical conditions?
Patients aged 20 to 64 years who have any of the following medical conditions can go directly to their optometrist or physicians and receive an eye examination once every 12 months : diabetes mellitus, glaucoma, cataract, retinal disease, amblyopia, visual field defects, corneal disease, strabismus. Prior to November 1, 2004, eye examinations were covered once every two years.
I am 71 and have glaucoma. Does OHIP still cover my eye examinations?
Yes. OHIP coverage for seniors has not been changed.
Do persons aged 20 to 64 with medical conditions affecting the eye need to get a physician referral in order to see their optometrist now?
Patients aged 20 to 64 who have conditions not listed above may also be covered for a regular eye examination.
Patients should discuss this with their primary health care provider. A requisition will be provided where appropriate for an OHIP covered eye examination. A requisition is valid for up to five years.
I am 52 and have diabetes. How often will OHIP pay for me to see my eye care physician or optometrist?
OHIP pays for you to have one eye examination every 12 months. OHIP also covers any follow-up care you require before you have your next major eye examination. Prior to November 1, 2004, OHIP covered eye examinations once every two years.
Do these changes to optometry services include services provided by an ophthalmologist?
The only change to ophthalmology services is that routine eye examinations for healthy adults aged 20 to 64 years are no longer covered. OHIP continues to cover all medically necessary services provided by ophthalmologists.
Are eye care services covered for people receiving social assistance?
The Ministry of Community and Social Services has established a program to ensure people receiving social assistance are covered for regular eye examinations as they have been in the past.
Persons in receipt of assistance under the Ontario Disability Support Program, Ontario Works or the Family Benefits Program will receive coverage for regular eye examinations. Coverage is once every two years.
If you have any questions, please call Client Services at the Ministry of Community and Social Services at 1 888 789-4199 1 888 789-4199 (toll free) or 416 325-5666 416 325-5666 (Toronto) or 1 800 387-5559 1 800 387-5559 (TTY).
How much will routine optometry eye examinations cost for people who are not covered by OHIP? Will the cost be regulated?
The optometrist determines patient fees. The ministry does not play a role in regulating these fees.
If you have any questions regarding eye care services that you have been charged for please contact : Ministry of Health and Long-Term Care at (613) 536-3103. Collect calls are accepted.