Navigating eye care coverage through the Ontario Health Insurance Plan (OHIP) can be confusing for many Ontarians. OHIP covers eye exams for people in certain age groups or those with specific medical or eye conditions.
OHIP doesn’t cover eye exams for all age groups or conditions. OHIP coverage applies as follows:
- Children aged 0–19 are eligible for one comprehensive eye exam every 12 months
- Adults aged 20–64 with specific conditions, like diabetes and glaucoma, are eligible for one comprehensive eye exam every 12 months
- Adults over the age of 65 are eligible for one comprehensive eye exam every 18 months, unless they have a specific condition, which would make them eligible for one comprehensive eye exam every 12 months.
Any individual without a valid OHIP card or not included in coverage will have to pay for the cost of their appointment.
What is OHIP?
The Ontario Health Insurance Plan (OHIP) is the public health insurance system providing Ontarians with access to essential medical services.
Funded by the provincial government, OHIP covers a wide range of healthcare needs, including hospital stays, doctor visits, and certain medical procedures.
Coverage varies depending on the type of care and the individual’s eligibility, such as age, residency status, or medical condition.
Who Is Eligible for OHIP-Covered Eye Exams?
OHIP provides coverage for eye exams for specific age groups and individuals with certain medical conditions. Here’s a breakdown of eligibility criteria:
1. Children & Teens (0–19)
Children 19 and under receive full OHIP coverage for one comprehensive eye exam every 12 months. These exams evaluate overall eye health and prescription needs and are crucial for detecting vision problems early, which can impact learning, development, and overall well-being. Follow-up appointments to look at a specific concern, if required, are also covered.
2. Seniors (65+)
Adults 65 or older qualify for one OHIP-covered comprehensive eye exam every 18 months. However, if an adult over 65 years of age has an eligible medical condition, OHIP covers one full eye exam every 12 months.
Seniors are at a higher risk of developing glaucoma, cataracts, and macular degeneration, so regular eye examinations are essential for safeguarding long-term vision health.
OHIP also covers up to 2 partial assessments annually. Ocular conditions that may require monitoring after a comprehensive exam include: retinal disease, diabetes, glaucoma, and corneal diseases.
3. Adults with Specific Medical Conditions (20–64)
Most adults between the ages of 20 and 64 are not eligible for OHIP-covered eye exams, however, if you have an eligible medical condition that affects your vision, eye care visits may be covered by OHIP. Covered conditions include:
- Diabetes
- Glaucoma
- Cataracts
- Retinal diseases
- Corneal diseases
- Optic nerve diseases
- Sudden-onset strabismus
For adults in this group, OHIP covers one comprehensive eye exam annually and up to 2 follow-up assessments, provided they are related to the OHIP-covered condition. If you’re unsure if your condition qualifies, consult your optometrist.
What Services Are Not Covered by OHIP?
While OHIP can provide foundational coverage, it does not cover some services. These frequently excluded tests and services include:
- Retinal imaging & optical coherence tomography (OCT scans), which capture detailed images for screening for macular degeneration or structural damage to the retina
- Visual field testing, a noninvasive test for peripheral vision loss or changes, unless it’s required for managing a condition covered by OHIP.
- Contact lens fittings or consultations, including fittings for astigmatism, dry eye, or other unique conditions
- Dry eye assessments for managing symptoms of chronic dry, red, irritated eyes
- Prescription eyewear consultations for updating or assessing a new prescription for standard eyeglasses
You will have to use private insurance or personal payment options for these services.
Why Are Regular Eye Exams Essential?
Even if you’re not in a group covered by OHIP, scheduling regular eye exams is a priority for preserving your vision and overall health.
Eye exams are more than getting a glasses prescription—comprehensive eye exams can help detect early signs of underlying health issues, such as diabetes and high blood pressure.
Skipping regular eye care could mean missing the opportunity to address these problems early on, leading to more serious complications later.
Eye Care for Your Whole Family
If you have questions about what OHIP covers or need help navigating your eye care options, the Old South Optometry team is here to help. Whether you’re booking your OHIP-covered exam or scheduling an eye exam to update your contact lenses or glasses, we’re committed to offering professional, compassionate care tailored to your needs. Reach out today to book an appointment with one of our experienced optometrists. Your healthy vision is our priority.
