OHIP and Eye Exams. Does OHIP cover eye exams?
Updated: May 12
Here is the latest from OHIP to us. Please feel free to reach out to us to book your eye exams or for more clarification in your case.
Ontario Health Insurance Plan INFOBulletin Implementing the New Optometry Services Agreement Changes to OHIP-insured services for the period of April 1, 2021 to March 31, 2025 To: Optometrists Category: Optometrist Services Written by: Provider Services Branch, Physician and Provider Services Division and Claims Services Branch, Health Programs and Delivery Division Date issued: March 30, 2023 Bulletin Number: 230311 The Ministry of Health (ministry) has been working with the Ontario Association of Optometrists (OAO) to implement the new Optometry Services Agreement (Agreement) for the period of April 1, 2021 to March 31, 2025. Background The Ministry of Health (ministry) and the Ontario Association of Optometrists (OAO) reached early consensus to implement some changes to optometry services under the Ontario Health Insurance Plan (OHIP) prior to finalizing the new Optometry Services Agreement:
As published in INFOBulletin 220406, Fee Schedule Code (FSC) increases were applied to annual eye exams for children and seniors retroactive to April 1, 2021.
As published in INFOBulletin 220801, payments to support investment in modernizing optometry service delivery were made in August 2022.
In order to implement the remaining elements of the Agreement, amendments have been made to the Schedule of Benefits for Optometry Services as described below. Fee Schedule Code increases effective April 1, 2023 Starting April 1, 2023, the following Fee Schedule Codes will have their fee rates increased in the Fee Schedule Master (FSM): Fee Schedule CodeDescriptionNew FeeV404Periodic oculo-visual assessment for patients age 19 years or less$51.00V406Periodic oculo-visual assessment for patients age 65 years or older$80.00V409Major eye examination for patients age 20 to 64 years$55.00V450Periodic oculo-visual assessment-Ontario Disability Support Program$48.00V451Periodic oculo-visual assessment-Ontario Works$48.00Please ensure that your billing software is updated to reflect the new Fee Schedule Code values for any services submitted on or after April 1, 2023. The updated Fee Schedule Master can be found on the Ministry of Health website. The Schedule has been updated to reflect the new fees. The Schedule of Benefits for Optometry Services can also be found on the Ministry of Health website. Overview of specific Schedule changes effective September 1, 2023 Please Note: Additional information regarding implementation of these changes will be communicated closer to the effective date. This bulletin outlines the changes to the Schedule of Benefits for Optometry Services that involve the creation of new fee codes, and revised fee codes/descriptions. The online version of the Schedule of Benefits for Optometry Services reflects changes that take effect on September 1, 2023 to facilitate the transition to the changes to coverage. The following changes are not applicable to optometry services rendered prior to September 1, 2023. Optometrists should continue to follow existing payment rules for any services rendered before September 1, 2023. New Complexity Modifiers Three new codes have been added to the Schedule effective September 1, 2023:
Glaucoma complexity premium
Child cycloplegic refraction complexity premium
Diabetes complexity premium
Revised Fee Codes / Descriptions The Ministry of Health (ministry) and the Ontario Association of Optometrists (OAO) formed the Optometry Appropriateness Modernization Working Group (OAMWG) to use evidence, best practices or expert opinion to identify and update payment for the delivery of OHIP insured optometry services to help ensure the most effective care for Ontario patients. Revisions to descriptions and/or payment requirements have been made to the following services effective September 1, 2023. Major Oculo-Visual Examination for patients aged 20 to 64 years
Revisions to the Major Oculo-Visual Examination for Patients aged 20 to 64 Years (V409) have been applied.
The list of eligible medical conditions for a V409 has been updated to:
Glaucoma requiring or having had treatment with medication, laser (excluding prophylactic laser peripheral iridotomy), or surgery
Cataracts / posterior capsular opacification with a visual acuity of 20/40 or worse in the best corrected eye, or when a surgery referral is made
Retinal disease that is acute, or is chronically progressive
Corneal disease that is acute, or is chronically progressive
Uveitis that is acute or chronic during episodes of active inflammation
Optic pathway disease that is acute, or is chronically progressive
Acquired cranial nerve palsy resulting in strabismus during the acute phase or until the condition resolves or stabilizes
Ocular drug toxicity screening for patients taking hydroxychloroquine, chloroquine, ethambutol or tamoxifen
Diabetes mellitus
Amblyopia and strabismus have been removed from the list of eligible medical conditions for a V409.
V409 will no longer be eligible for payment with a requisition from a physician or registered nurse holding an extended certificate of registration [(RN (EC)].
Oculo-Visual Minor Assessments for patients aged 20 to 64 Revisions to the Oculo-Visual Minor Assessments for patients aged 20 to 64 years (V408) have been applied:
The minor assessment is with respect to any eligible medical conditions listed for an insured major eye exam and present at the previous major eye (V409), and
A maximum of two services per 12-month period per patient following the major oculo-visual assessment (V409).
Major Oculo-Visual Examination for patients aged 65 years or older Revisions to the Major Oculo-Visual Examination for patients aged 65 or older have been applied:
Patients aged 65 years or older with no eligible medical conditions may receive a major oculo-visual examination once per 18-month period.
Patients aged 65 years or older with one or more eligible medical conditions may receive a major oculo-visual examination once per 12-month period.
Oculo-Visual Minor Assessments for patients aged 65 years or older Revisions to the Oculo-Visual Minor Assessments for patients aged 65 years or older have been applied:
A maximum of two services per 12-month period per patient following the major oculo-visual assessment for a patient with one or more eligible medical conditions; or,
A maximum of two services per 18-month period per patient following the major oculo-visual assessment for a patient with no eligible medical conditions.
Automated Visual Fields Assessment Revisions to the Automated Visual Fields Assessment (V410) have been added. The service is insured when clinically necessary to determine the extent and sensitivity of a patient’s visual fields for patients with the following conditions:
Retinal disease (including diabetic retinopathy)
Glaucoma
Active optic pathway disease
Ocular drug toxicity screening
Acquired cranial nerve palsy resulting in strabismus
Clarification changes The Schedule of Benefits for Optometry Services has been amended to clarify that the following services are not common or elements of an insured major oculo-visual examination or a minor assessment:
Comprehensive binocular vision assessment;
Myopia control management
Dry eye assessment and treatment procedures
Macular pigment optical density
Aberrometry
All forms of anterior and posterior segment imaging, including but not limited to: retinal imaging, optical coherence tomography and meibography
Pachymetry
Screening visual fields
Low vision assessment/rehabilitation
Services by virtual means, including telephone, video or text
Foreign body removal
Corneal topography
Eyelash epilation
Vision therapy
Axial length measurements
Travel expenses incurred to provide services outside of the usual geographic area of practice.
These clarification changes will be reflected in Schedule of Benefits for Optometry Services effective September 1, 2023. However, they are currently not part of, and have never been considered part of, a routine eye exam insured under OHIP. Keywords/Tags Optometry Services Agreement; optometrists; payments; changes to OHIP-insured optometry coverage Contact information Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524.
For More Information Call ServiceOntario, INFOline at: 1–866–532–3161 (Toll–free) In Toronto, (416) 314–5518 TTY 1–800–387–5559. In Toronto, TTY (416)327–4282 Hours of operation: Monday to Friday, 8:30 a.m. – 5:00 p.m.
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