Does OHIP Pay for Eye Exams? How Does OHIP Work?
OHIP (Ontario Health Insurance Plan) takes care of many health services, including eye examinations that meet certain requirements such as ages 19 and younger to ages 65 and older. Below, we will answer common questions on OHIP eye exam coverage and important information you should know.
Is Optometry Covered By OHIP?
Yes! OHIP offers limited coverage for optometry, including one free comprehensive eye examination from an optometrist once per year. Follow-up visits may be covered in some circumstances, which depends on your age and specific medical condition.
What Does OHIP Cover in Optometry?
Besides offering one free comprehensive eye exam yearly, the OHIP can cover partial exams (follow-up visits) if a patient has specific eye conditions.
What Does OHIP Not Cover in Optometry?
OHIP coverage isn’t available for those seeking second opinions, prescription glasses, prescription sunglasses, contact lenses, laser eye surgeries, other elective/cosmetic eye treatments, special or advanced testing and prescribed medication. Highly recommended to find and acquire private health insurance plans through your workplace or family to help cover ongoing health expenses. Also, there are other social assistance programs available such as OW and ODSP to help cover eye exams and glasses.
What Age(S) Does OHIP Cover Eye Exams?
Generally, OHIP eye exam coverage is dictated by age:
- 19 years and younger: Individuals aged 19 and under are eligible for one eye exam yearly and OHIP-insured follow-up visits if they have specific eye conditions. A child can have their first eye exam starting at 3 months of age!
- 20 to 64 years: Individuals aged 20 to 64 years are eligible for an OHIP-insured comprehensive eye exam yearly by an optometrist if they have an eligible sight-threatening condition, such as:
- Diabetes mellitus,
- Glaucoma
- Cataracts
- Retinal disease
- Corneal disease
- Uveitis
- Optic nerve diseases like optical nerve pathway disease
- Sudden onset of crossed-eyes (strabismus)
- Persons taking certain medications may also be eligible
A person with the above conditions qualifies for one comprehensive eye exam and a maximum of two additional OHIP-insured hospital visits yearly.
- 65 years and older: Persons aged 65 and older with the above eye conditions qualify for one OHIP-insured eye exam from an optometrist. If a senior doesn’t have any sight-threatening condition, they also still qualify for one OHIP-insured comprehensive eye exam every 1.5 years.
Does OHIP Cover Glasses?
No! OHIP doesn’t cover the cost of prescription eyewear (glasses, sunglasses or contact lenses). Typically, you need to rely on private insurance plans or pay out-of-pocket for eyeglasses and contact lenses.
However, there are exceptions where assistance may be available, for example, via the ADP (Assistive Devices Program), open to persons who have low vision and need specialized glasses or magnifiers due to long-term disabilities. Individuals who are eligible for Ontario Works or ODSP (Ontario Disability Support Program) can also get assistance and benefits when getting prescription eyeglasses.
What Does OHIP Cover for Seniors Over 65?
As mentioned, seniors aged 65 and above with eligible eye conditions qualify for one OHIP-insured eye exam from an optometrist. Seniors who don’t have any sight-threatening conditions can still qualify for one OHIP-insured comprehensive eye exam every 1.5 years.
All patients aged 65 and over are eligible for a maximum of two OHIP-insured “partial examinations” in between regular check-ups if needed. For example, a patient with glaucoma is eligible for two additional OHIP-insured visits per year to have their eye pressures checked. A patient aged 65 and over may choose to visit their optometrist for an appointment at any time outside of these insured services. Fees for those examinations apply. On March 24, 2023, the Ontario Government issued a media release about these changes, which you can read here. Also visit ohipupdates.ca to learn more.
What Does OHIP Cover for Cataract Surgery?
Since cataract surgery is a medically necessary eye treatment for restoring vision, it is OHIP-covered. The coverage takes care of the surgical procedure itself (surgeon fees, surgical facility fees, and cost of anesthesia).
Standard intraocular lenses are also covered, as well as medically-necessary care (pre-operative & post-operative). Other intraocular lenses recommended by the surgeon or ophthalmologist may not be covered. Any costs not covered by OHIP will always be explained by the practitioner for you to make a decision before proceeding. OHIP coverage may not include advanced pre-operative tests, prescription glasses or contacts, as well as elective laser procedures.
Please don’t assume all health products and services are covered by the government in Canada. If you would like to know what is covered or not covered, we highly recommend you ask the practitioner and they can share all the important details for you to make an informed decision. The medical practitioners don’t control what benefits the government offers to citizens with valid health cards. They’re just the service provider. Any complaints or concerns about our health system, please address them to your local MP or to the government directly.
Does OHIP Pay for Eye Exams?
Yes! However, your age and eye condition will dictate the frequency and extent of OHIP-covered eye exam treatment and services you will get. Having a valid health card can give you some benefits and with this, the government will help reimburse the medical practitioner for certain services.
Keep in mind, the medical practitioner does not get paid right away. Each medical practitioner must submit OHIP billing to the government in order to get reimbursed at a later date after reconciliation. If the billing is not done correctly or meets government standards then the medical practitioner will not be reimbursed properly. Practitioners must trust the patient they’re coming in for legitimate OHIP covered health concerns in order to proceed with OHIP services.
How Does Eye Test OHIP Coverage Work?
As discussed, OHIP coverage for eye exams is based largely on age and the presence of specified medical conditions. Eligibility requirements are determined by certain conditions. For example, being a resident of Ontario, a Canadian citizen, or falling into other specified categories. Another condition is that you have applied for permanent residency or have a valid work permit; in that case, you simply need to apply for OHIP coverage to get a valid health card. Once you’re all set up, we recommend visiting licensed Ontario optometrists at clinics like Kodak Lens Vision Centres offering OHIP-covered eye exams.
The Ontario Health Insurance Plan (OHIP) pays for many health services you may need. OHIP is Ontario’s health care plan. Click here to learn how to apply for OHIP and get a health card. You need to apply and, once you’re approved, you’ll get an Ontario health card. Your health card proves you’re covered by OHIP – that’s why you’ll need to show it every time you see your doctor, optometrist, visit an emergency room, have a medical test or go for surgery. There is no longer a waiting period for OHIP coverage. If you are eligible, you will have immediate health insurance coverage. Find out if you qualify.
Are All Eye Exams and Testing Covered By OHIP?
No! Some diagnostic and advanced tests, like standalone screenings, retinal photography or ocular coherence tomography aren’t covered. Eye exams for 3rd party requirements, including employment pre-screening, police application, and a pilot’s license are also not covered. Patients who require a form (i.e. MTO, application, HR, work, legal etc.) to be completed is not covered by OHIP and subjected to a service fee based on each medical practitioner’s discretion.
Are All Referrals to an Ophthalmologist Covered Under OHIP?
No. Referrals are only covered if they are from primary care providers, meaning an optometrist or family doctor. Referrals must also be for medically necessary procedures, tests, or visits. It’s worth noting that routine eye examinations are covered depending on specific rules based on age and specific medical conditions. If you have been referred to an Ophthalmologist, the initial consultation may be covered by OHIP, but any offerings, treatments, testing, products or services etc. is not always covered. We advise you to ask the ophthalmology clinic to disclose any costs involved when visiting after being referred.
I Have a Referral from My Family Doctor. Does That Guarantee It Will Be Covered Under OHIP?
No. A referral doesn’t automatically guarantee coverage. The referral must be for medically necessary treatments: treatment for glaucoma, retinal conditions, corneal diseases, cataracts, etc. Cosmetic procedures, prescription glasses, and contacts aren’t typically covered, even when there is a referral. As mentioned above, please share all details why you have been referred and to ask the clinic to disclose any costs involved based on the reason for your visit. As regulations and OHIP coverage has changed over the years, please always be expected to pay when applicable. Your knowledge and health will thank you.
Looking for an OHIP Optometrist?
If yes, look no further. KODAK Lens Vision Centres have optometrists offering OHIP-covered eye exams. Book an OHIP-covered comprehensive eye exam NOW. You can also make doctor’s appointments by calling: 647-952-1099. Find out more about OHIP coverage and other vision care services. Remember to always ask if you’re unsure and don’t assume before visiting a medical clinic. Our web chat on our website is available for all general inquiries and we look forward to further assisting you with your eye health needs.