Visiting your optometrist for routine eye exams is key to maintaining good ocular health and vision. Everyone benefits from these visits, which is why all Ontarians are encouraged to undergo an exam regardless of their age or health status.
The Ontario Health Insurance Plan, or OHIP, recognizes the importance of eye health. However, OHIP’s focus is on care that is deemed medically necessary. This doesn’t include routine eye exams for everyone.
Rather, OHIP provides coverage for vision care under certain circumstances:
- Annual eye exams for children 19 and under and seniors 65 and older.
- Annual eye exams for individuals between the ages of 20 and 64 diagnosed with medical conditions that impact eye health.
- Emergency eye care visits like eye injuries, sudden vision loss, infection, or foreign bodies.
Understanding OHIP
Taking care of our health and wellness is an all-encompassing priority that includes our vision and dental care. Some readers may be unaware that Ontario’s provincial healthcare plan covers some of the costs associated with vision care.
The Ontario Health Insurance Plan (OHIP) is a provincial-run healthcare program that provides coverage for a range of essential medical services to residents of Ontario. OHIP aims to offer all eligible residents access to necessary healthcare without direct charges.
OHIP plays a small role in covering specific eye exams and treatments.
Who Qualifies for OHIP?
Living in Ontario isn’t the only qualifying factor for coverage under the provincial healthcare plan. To qualify for OHIP, individuals must:
- Be a Canadian citizen or permanent resident.
- Physically reside in Ontario for at least 153 days in any 12-month period.
- Physically be in Ontario for at least 153 days of the 183 days immediately after moving to it.
- Make Ontario their primary residence.
Those who meet these criteria but haven’t applied can apply online, in person at their local ServiceOntario center, or by mail. Applicants must present proof of identity, residency, and citizenship or immigration status during the application process.
Vision Care Covered Under OHIP
While caring for our ocular health is important, OHIP doesn’t cover every aspect of vision care. Rather, OHIP specifically covers essential medical services, thereby focusing on care for vulnerable individuals who are at risk of developing eye conditions.
Vision care under OHIP includes:
- Annual Eye Exams for Children and Seniors: Routine eye exams are covered once a year under OHIP for children 19 and younger and Seniors 65 years or older. These age groups are experiencing developmental changes to their ocular health or are more susceptible to age-related eye conditions.
- Annual Eye Exams for Specific Medical Conditions: This includes individuals between the ages of 20 and 64 with certain medical conditions that can adversely affect their vision and ocular health. These conditions require periodic assessments to monitor the progression of the eyes’ condition, the efficacy of treatment, and its impact on visual clarity.
- Coverage for Eye Emergencies: Emergency eye care is covered under OHIP. This may include sudden vision impairment, eye infections, injuries, and foreign bodies. These conditions require immediate medical care to prevent damage or vision loss, making them medically necessary.
Why OHIP Provides Coverage for Vulnerable Health Groups
Children 19 and under and Seniors 65 and older are going through ocular changes that can impact their overall health and vision, which is why OHIP provides annual coverage for their routine eye exams.
Monitoring children’s vision and ocular health is important because children’s eyes experience rapid growth from infancy to adolescence, leading to frequency shifts in their vision prescription.
According to the Canadian Association of Optometrists, children should have annual eye exams until they turn 19. Children are also recommended to have an eye exam at the following times:
- First eye exam between 6 to 9 months.
- At least one eye exam between 2 to 5 years old.
- Annual eye exams from 6 to 19 years old.
Additionally, aging increases the risk of developing vision challenges, which is why annual eye exams for individuals 65 and over are vital. Some of these problems can include:
- Trouble distinguishing colors
- Low vision and difficulty seeing at night
- Cataracts
- Age-related macular degeneration (AMD)
- Vision injuries related to falls
Additionally, OHIP extends its coverage for annual exams to those between the ages of 20 to 64, with specific medical conditions that could adversely affect their vision and ocular health. These include:
- Type 1 or type 2 diabetes
- Glaucoma
- Cataracts
- Macular degeneration
- Retinal disorders
If these conditions are left unchecked, they can lead to severe complications, including vision loss.
By encouraging routine eye care for these patients, OHIP aims to monitor disease progression, enhance treatment plans, minimize complications, and reduce the long-term healthcare costs associated with managing advanced eye diseases.
Aside from supporting more vulnerable health groups, OHIP doesn’t cover routine eye exams for patients between the ages of 20 and 64. These individuals aren’t experiencing the same developmental changes in their ocular health as children, older adults, and those with specific medical conditions.
Nonetheless, adults 20 to 64 are still encouraged to have their routine eye exam at least once every two years to monitor their overall ocular health and adjust for any changes in visual clarity.
In addition to private insurance, the government of Ontario offers basic vision coverage for eligible individuals under its financial assistance plans:
Connect with our Team
Navigating healthcare coverage can be complex, but understanding OHIP’s requirements for vision care can help you make the most of your benefits.
You can always connect with our team at Arc Eye Care to verify whether your visit will be covered by OHIP. Contact us to schedule an appointment for your routine eye exam.
