Whether or not you have Ontario Health Insurance Plan (OHIP) coverage for eye exams can be confusing. Routine eye exams for otherwise healthy patients aged 20 to 64 are not covered by OHIP and they must cover the cost of eye exams themselves if they don’t have private insurance. However there are exemptions.
What OHIP Covers
OHIP does cover annual eye exams for patients under 20 years of age and those 65 years of age or older. It also covers major eye exams for all patients with medical conditions that affect the eye such as infections or diseases.
OHIP also covers ophthalmic examinations conducted or interpreted by an ophthalmologist for OHIP eligible persons of any age who have medical conditions requiring an ophthalmic examination.
Those not covered by OHIP for regular eye exams and not otherwise covered by private insurance, must pay for eye exams out of pocket. Each optometrist determines patient fees and the ministry does not regulate these fees.
Coverage for Seniors, Children and Teens
People who are 65 years and older and those younger than 20, are covered for a routine eye exam by an optometrist once every 12 months. Any follow-up assessments that may be required are also covered by OHIP.
Coverage for Certain Medical Conditions
Patients of any age with specified medical conditions and diseases affecting the eyes are insured for specified ophthalmology services. If you are between the ages of 20 and 64 years old with certain medical conditions affecting the eyes, OHIP will cover a regular eye exam once every 12 months.
You are covered under OHIP for the following conditions:
- Diabetes mellitus
- Glaucoma
- Cataract
- Retinal disease
- Amblyopia (lazy eye)
- Visual field defects (loss of part of the usual field of vision)
- Corneal disease
- Strabismus (crossed eyes)
- Recurrent uveitis (an inflammation of the uvea, the middle layer of the eye that consists of the iris, ciliary body and choroid)
- Optic pathway disease
People between the ages of 20 and 64 who have certain medical conditions not listed above, may also be covered for regular eye exams. Your primary health care provider will be able to tell you if you qualify.
If your family doctor finds you have a medical condition that requires regular monitoring, a requisition will be provided for OHIP covered eye exams. A requisition is valid for up to five years.
Coverage under MCSS
Under the Ministry of Community and Social Services (MCSS), people can receive coverage. If you get assistance through one of their programs, you can receive coverage for routine eye exams once every two years. These programs are as follows:
- Ontario Disability Support Program
- Ontario Works
Ontario Disability Support Program
Persons and their families receiving Ontario Disability Support can receive routine eye exams once every two years, if OHIP coverage is not available. All eligible family members can also receive new lenses and frames every three years.
Assistance for the cost of new lenses for children under 18 years of age, may be provided anytime there is a change in prescription. The ODS program will also assist with the cost of eyeglass repairs for you, your spouse and your children under the age of 18.
To get assistance with the cost of prescription eyeglasses, you need to:
- contact your local Ontario Disability Support Program office and ask for a Vision Care benefit authorization form
- take the form with you to your optometrist or optician, who will fill it in when you get glasses, frames or repairs. Sign the form.
You don’t have to pay for your glasses up front, as your eye doctor will send the completed form to the Ministry of Community and Social Services to be reimbursed.
The Vision Care benefit will cover prescription glasses up to a maximum amount, but if you choose more expensive lenses or frames, you will need to pay the optometrist or optician the difference.
Always present your Ontario Health card or Statement of Assistance whenever you have an eye exam.
Ontario Works
If you are receiving Ontario Works, you and your family may be eligible for certain health-related benefits, including vision care.
Eye Examinations
For each member of the family who is between the ages of 20 and 64, Ontario Works will cover the cost of routine eye examinations once every 24 months.
Adults between the ages of 20 and 64 who have medical conditions such as infection, disease and injury requiring regular eye exams, will receive coverage for eye exams every 12 months under OHIP.
Eyeglass Costs
Costs may be approved for eyeglass lenses and frames, repairs or replacements under the following conditions:
- when necessary because of a significant change in prescription
- if the benefit supports the person’s employability or participation requirements
You must have a prescription from an ophthalmologist, optometrist or physician before frames and lenses can be approved.
Vision Care for Children
You may also be able to get help to pay for prescription glasses and eyeglass repairs for your children under Ontario Works.
Questions about the coverage provided under these programs can be answered by calling Client Services at MCSS at 1-888-789-4199 toll free or at the Toronto number 1-4l6-325-5666 or 1-800-387-5559 (TTY).
