insurance and ohip

Beginning September 1, 2023, a patient aged 20 to 64 with one or more of the following potentially sight-threatening conditions is eligible for an OHIP-insured comprehensive eye examination by an optometrist (MAXIMUM ONCE EVERY 12 MONTHS).

1. Diabetes. A patient with a confirmed diagnosis of diabetes is eligible for an annual OHIP-insured comprehensive eye examination. The optometrist may ask for a list of medications or a letter from a physician to verify the diagnosis of diabetes.
   
   
2. Glaucoma. A patient with a confirmed diagnosis of glaucoma is eligible for an annual OHIP-insured comprehensive eye examination. A patient who is being examined to determine whether or not they have glaucoma (e.g., because they have risk factors such as elevated eye pressure or a family history of glaucoma) is not eligible for OHIP-insured eye examinations.
   
   
3. Cataracts. A patient with early cataracts that are not significantly impairing vision (better than 20/40 in the better eye) is not eligible for OHIP-insured eye examinations. However, if during the examination it is determined that the cataract impacts a patient enough that surgery is required, then that examination and referral is covered by OHIP.
   
   
4. Retinal Disease.  A patient with either an acute retinal condition (e.g., a new retinal detachment) or a progressive retinal condition (e.g., macular degeneration) is eligible for an OHIP-insured comprehensive eye examination. A patient with a stable retinal condition (e.g., a longstanding repaired retinal detachment) is not eligible for OHIP-insured eye examinations.
   
   
5. Corneal Disease. A patient with an acute corneal disease (e.g., a new corneal ulcer) or a progressive corneal disease (e.g., Fuch’s dystrophy) is eligible for an OHIP-insured comprehensive eye examination. A patient with a stable corneal condition (e.g., a longstanding corneal scar) is not eligible for OHIP-insured eye examinations.
   
   
6. Optic Nerve Pathway Disease.  A patient with an acute optic nerve pathway disease (e.g., a new stroke affecting vision) or a progressive optic pathway disease (e.g., a pituitary gland tumor) is eligible for an OHIP-insured comprehensive eye examination. A patient with a stable nerve condition (e.g., a longstanding, stable nerve damage from an old stroke) is not eligible for OHIP-insured eye examinations.
   
   
7. Uveitis. The condition must be active at the time of the examination for the patient to be eligible for an OHIP-insured comprehensive eye examination. A patient who has had uveitis in the past but the condition is not currently active is not eligible for OHIP-insured eye examinations.
   
   
8. Patients taking any of the following medications: Chloroquine, Hydroxychloroquine, Ethambutol, Tamoxifen are eligible for an annual OHIP-insured comprehensive eye examination.
   
   
9. Sudden onset of strabismus (crossed-eyes) due to injury or disease. A patient with a sudden onset of strabismus (crossed-eyes) is eligible for an OHIP-insured comprehensive eye examination.  A patient with stable, longstanding strabismus is not eligible for OHIP-insured eye examinations.

A referral made by a physician to an optometrist is only insured by OHIP if one of the above 9 conditions exists.

In addition, a patient with any of the above 9 conditions is eligible for a MAXIMUM OF TWO OHIP-insured follow-up “partial examinations” annually for that condition. For example, a patient with glaucoma is eligible for two additional OHIP-insured visits per year to have their eye pressures checked.

Evidence shows that the conditions of strabismus (crossed-eyes) and amblyopia (lazy eye) typically remain stable after childhood. Routine monitoring after childhood does not change how these conditions affect vision. As such, these are no longer eligible conditions for OHIP-insured eye examinations as of September 1, 2023.

Beginning September 1, 2023, a patient aged 65 and over with one or more of the following potentially sight-threatening conditions is eligible for an OHIP-insured comprehensive eye examination ONCE EVERY 12 MONTHS from an optometrist.

1. Diabetes. A patient with a confirmed diagnosis of diabetes is eligible for an annual OHIP-insured comprehensive eye examination. The optometrist may ask for a list of medications or a letter from a physician to verify the diagnosis of diabetes.
   
   
2. Glaucoma. A patient with a confirmed diagnosis of glaucoma is eligible for an annual OHIP-insured comprehensive eye examination. A patient who is being examined to determine whether or not they have glaucoma (e.g., because they have risk factors such as elevated eye pressure or a family history of glaucoma) is eligible for an OHIP-insured comprehensive eye examination every 18 months.
   
   
3. Cataracts. A patient with cataracts that are significantly impairing vision (worse than 20/40 in the better eye) or requiring a surgical referral, is eligible for an OHIP-insured comprehensive eye examination 12 months after their last one. A patient with early cataracts that are not significantly impairing vision (better than 20/40 in the better eye or not requiring a surgical referral), is only eligible for an OHIP-insured comprehensive eye examination every 18 months.
   
   
4. Retinal Disease. A patient with either an acute retinal condition (e.g., a new retinal detachment) or a progressive retinal condition (e.g., macular degeneration) is eligible for an OHIP-insured comprehensive eye examination 12 months after their last one. A patient with a stable retinal condition (e.g., a longstanding repaired retinal detachment) is only eligible for an OHIP-insured comprehensive eye examination every 18 months.
   
   
5. Corneal Disease. A patient with an acute corneal disease (e.g., a new corneal ulcer) or a progressive corneal disease (e.g., Fuch’s dystrophy) is eligible for an OHIP-insured comprehensive eye examination 12 months after their last one. A patient with a stable corneal condition (e.g., a longstanding corneal scar) is only eligible for an OHIP-insured comprehensive eye examination every 18 months.
   
   
6. Optic Nerve Pathway Disease. A patient with an acute optic nerve pathway disease (e.g., a new stroke affecting vision) or a progressive optic pathway disease (e.g., a pituitary gland tumor) is eligible for an OHIP-insured comprehensive eye examination 12 months after their last one. A patient with a stable nerve condition (e.g., a longstanding, stable nerve damage from an old stroke) is only eligible for an OHIP-insured comprehensive eye examination every 18 months.
   
   
7. Uveitis. A patient with uveitis that is active at the time of examination is eligible for an OHIP-insured comprehensive eye examination 12 months after their last one. A patient who has had uveitis in the past but the condition is not currently active is only eligible for an OHIP-insured comprehensive eye examination every 18 months.
   
   
8. Patients taking any of the following medications: Chloroquine, Hydroxychloroquine, Ethambutol, Tamoxifen are eligible for an annual OHIP-insured comprehensive eye examination.
   
   
9. Sudden onset of strabismus (crossed-eyes) due to injury or disease. A patient with a sudden onset of strabismus (crossed-eyes) is eligible for an OHIP-insured comprehensive eye examination 12 months after their last one.  A patient with stable, longstanding strabismus is only eligible for an OHIP-insured comprehensive eye examination every 18 months.
   
   

Beginning September 1, 2023, a patient aged 65 and over without one of the above 9 potentially sight-threatening conditions is eligible for an OHIP-insured comprehensive eye examination ONCE EVERY 18 MONTHS from an optometrist.

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.