What you should know about OHIP for vision care
Brief overview
Ontario’s Health Insurance Plan (or OHIP) allows the province to cater to multiple health services for qualified/eligible individuals¹. On March 21, 2023, the OAO (Ontario Association of Optometrists) signed a new 4-year funding agreement on how OHIP-insured eye care services will be offered, effective from the 1st of September 2023. This new agreement was inspired by clinical evidence on appropriate eye care, expert opinion, and best practices.
Following the OHIP changes, Ontario residents of all ages who meet the new eligibility requirements can expect to continue enjoying high-quality publicly funded eye care services. We’ve gone through the process of assessing the 2023 OHIP changes in-depth. Here’s what you should know:
OHIP changes for annual exams
Before, all seniors aged 65 or more were entitled to one yearly eye exam.
As of the 1st of September, 2023, only seniors with an eligible medical/health condition affecting their eyes (like glaucoma, macular degeneration, or diabetes) are entitled to one eye exam annually. Seniors without eligible conditions are entitled to one eye exam every 1.5 years (or 18 months)². This change is meant to prioritize care for seniors who need it the most.
The change also aligns with timeframes for other provinces like Nova Scotia and Manitoba that ensure healthy seniors get one eye exam every two years.
OHIP changes for follow-up assessments
Before, seniors aged 65 and above were eligible for unlimited minor follow-up visits after going for their annual eye exam.
As of the 1st of September, 2023, only seniors with eligible health conditions affecting the eyes qualify for minor follow-up assessments. The assessments have been capped to a maximum of two every year.
Seniors without eligible conditions will also get a maximum of two minor follow-up assessments. However, this will be after every 1.5 years (or 18 months) following their yearly eye exam³.
These changes also ensure follow-up assessments are available to the vast majority who need them.
OHIP changes on eligible conditions vs. age
Going forward, adults and seniors residing in Ontario must have certain eligible medical conditions and prove eligibility to enjoy OHIP-insured eye exams and follow-up assessments. What’s more, the severity of the eligible condition will also dictate the frequency of eye exams i.e., more severe conditions will have priority. The changes are in line with documented research for the conditions in question.
Let’s discuss these changes in-depth with respect to age and underlying conditions:
I. Changes for those aged 19 or below
If you are aged 19 years or below, your OHIP coverage for eye exams remains the same.
Individuals in this age group qualify for one OHIP-insured eye examination annually from an optometrist. They also qualify for follow-up OHIP-insured partial assessments in between check-ups for specific vision/eye conditions. However, like before, visiting another optometrist to seek a second opinion on a diagnosis isn’t covered.
II. Changes for those aged 20 to 64 years
a. Qualified for OHIP-insured eye exam
As of the 1st of September 2023, individuals aged 20 to 64 years with any one or more severe vision-threatening conditions qualify for one OHIP-insured eye exam by an optometrist yearly. The list of approved conditions includes:
- Diabetes (confirmed diagnosis)
- Glaucoma (confirmed diagnosis)
- Cataracts (worse than 20/40 vision or requiring surgery referral)
- Retinal disease (acute or progressive retinal condition)
- Corneal disease (acute)
- Optic nerve pathway disease (acute)
- Uveitis (active)
- Crossed eyes (suddenly, due to disease or injury)
- Individuals who take certain medications i.e., Tamoxifen, Ethambutol, chloroquine, and hydroxychloroquine
b. Not qualified for OHIP-insured eye exam
Individuals aged 20 to 64 years with one or more of the following conditions listed below (and the respective severity) don’t qualify for an OHIP-insured eye exam.
- Unconfirmed diabetes
- Unconfirmed glaucoma, regardless of whether or not they have risk factors like family history when being examined
- Cataracts that don’t impact vision significantly i.e., better than 20/40 vision
- Stable retinal condition
- Stable corneal condition
- Stable Optic nerve pathway disease
- Inactive uveitis (even if there is a history of uveitis)
- Stable/long-standing strabismus (crossed eyes)
III. Changes for seniors aged 65 years and above
Seniors aged 65 or more with any one or more of the sight-threatening conditions below qualify for one OHIP-insured comprehensive eye exam from an optometrist every year (every 12 months) or every 1.5 years (every 18 months) if the condition isn’t very severe.
a. Seniors Qualified for OHIP-insured eye exam (every 12 months)
As of the 1st of September, 2023, seniors must have any one or more of the severe vision-threatening conditions (and the respective severity) to qualify for a yearly OHIP-insured eye exam by an optometrist (every 12 months).
- Diabetes (confirmed diagnosis). A letter from a physician and a list of medication/s may be required to verify diabetes diagnosis.
- Glaucoma (confirmed diagnosis)
- Cataracts (worse than 20/40 vision)
- Retinal disease (acute or progressive)
- Corneal disease (acute)
- Optic nerve pathway disease (acute)
- Uveitis (active during examination)
- Seniors with crossed eyes (suddenly due to disease or injury)
- Seniors taking certain medications i.e., Tamoxifen, Ethambutol, chloroquine, and hydroxychloroquine
b. Seniors qualified for an OHIP-insured eye exam (every 18 months)
Seniors aged 65 or more qualify for an OHIP-insured eye exam from an optometrist every 1.5 years if they have the following condition and respective severity:
- Unconfirmed glaucoma (but examined due to the existence of risk factors)
- Early cataracts (that doesn’t significantly impair vision)
- Stable retinal condition
- Stable corneal disease
- Stable optic nerve pathway disease
- Inactive uveitis (with history)
- Long-standing crossed eyes
In a nutshell, the frequency of eye exams (i.e., after 1 year or 1.5 years) among seniors will be dictated by the severity/progression of the disease in question. Those with stable or unconfirmed cases will wait slightly longer i.e., 18 months vs. 12 months for confirmed and/or severe cases. OHIP changes for those aged 20 to 64 prioritize confirmed and severe cases. This means those who are 20 to 64 years old don’t qualify for an annual OHIP-insured eye exam unless their sight-threatening condition is confirmed and/or severe.
For OHIP-insured eye care in Toronto and the Greater Toronto Area, visit Kodak Lens Vision Centre and get examined by professional and highly experienced optometrists.
For more information on OHIP changes call: 647-952-1099 or click here to ask a question online.