Eye exams are one of the easiest ways to stay on top of your vision. They’re not only about seeing clearly—they’re about making a conscious effort to understand your eyes and keep them healthy. However, eye care can be overwhelming when it comes time to consider insurance coverage. For Ontario residents, OHIP can often be an incredible help, but you might be wondering—does OHIP cover eye exams?
Usually, OHIP covers 1 eye exam every 12 months for:
- Children aged 19 and under
- Seniors aged 65 and older
- Adults between 20-64 with qualifying previously-diagnosed medical conditions
It’s important to note that eligibility can vary depending on some specific situations.
Regardless of OHIP-coverage, most optometrists recommend regular routine eye exams, even in the absence of any symptoms or signs, on a yearly basis. These exams serve 2 main purposes:
- To establish a baseline of both eye health (i.e. eye pressure, retinal and optic nerve health, etc)
- To establish a baseline of visual functioning and abilities (i.e. visual acuity, prescription, eye muscle functioning, etc)
This baseline will be added to at each visit and will be used as a reference point to determine if anything is changing, and if the changes are “normal aging changes” or if they might be pathologic changes. Catching suspicious changes early on may allow for intervention to prevent or delay sight or even life threatening conditions.
What Does OHIP Cover?
OHIP, the Ontario Health Insurance Plan, is a government-run health insurance program designed to provide Ontario residents with access to essential medical services. OHIP is designed to make sure that you receive any necessary healthcare without having to worry about surprise bills.
Usually, OHIP covers:
- Visits to your family doctor
- Hospital stays and emergency services
- Laboratory tests and radiology services
- Certain dental surgeries performed in hospitals
- Limited podiatry services
- Ambulatory services, including some optometry services
OHIP aims to make healthcare accessible and affordable, but it isn’t a universal answer to any and all healthcare costs, as it does have specific limitations and coverage details. So how does OHIP cover eye care?
When Does OHIP Cover Eye Exams?
When you think about eye exams, you likely recall getting a new prescription and spending some time with your optometrist working through a series of different tests. These tests are a crucial part of staying healthy; eye exams let your optometrist look out for potential problems that otherwise might go undiagnosed.
However, there is a financial side to eye care that can often be overlooked. In Ontario, OHIP covers eye exams in the following situations:
- For children aged 19 and younger, one eye exam will be covered once per year. Partial examinations will also be covered for specific eye and vision problems such as infections or abrasions.
- For seniors aged 65 and older, one eye exam will be covered once per year if they’re experiencing a previously diagnosed eligible condition. If a person aged 65 and older is not experiencing these conditions, one eye exam will be covered once every 18 months, along with 2 other partial examinations if required.
- For adults aged 20-64, one eye exam will be covered once per year if they’re experiencing an eligible eye condition. Two partial eye exams will also be covered per year to monitor a previously diagnosed condition.
If you don’t fall into these categories, regular eye exams might not be covered by OHIP. However, it’s crucial to check with your optometrist for specific eligibility criteria and updates on coverage.
What Conditions Affect OHIP Coverage?
In Ontario, there are nine specific situations when OHIP will cover eye exams for adults aged 20-64. These include:
- Diabetes, as it can damage the blood vessels in the eye and cause permanent damage
- Glaucoma, a group of eye conditions known to affect intraocular pressure and permanently damage the optic nerve
- Visually impactful Cataracts, the clouding of the eye’s natural lens degrading one’s ability to see clearly
- Progressing Retinal conditions, such as detachment or degeneration
- Progressive Corneal conditions, such as an ulcer or trauma
- Optic nerve damage or disease, such as an optic neuritis or a stroke to the optic nerve
- Active Uveitis, where the inside of the eye becomes inflamed
- When a patient is taking a certain specific medications known to affect the eye
- The sudden development of certain extreme changes in the eye or visual functioning, such as the sudden onset of crossed eyes
If you’re experiencing any of these conditions, your visit to the optometrist may be OHIP-covered once a year alongside two partial tests to monitor any eye-related changes. Regardless of OHIP or other benefits, most of these conditions warrant a proper optometric assessment and should not be delayed.
How Much Does an Eye Exam Cost in Ontario?
If you’re outside the OHIP coverage brackets and don’t have any type of private or employment benefits, you may need to pay out-of-pocket for your eye exam. Even with OHIP or private benefits coverage, some advanced testing required may not be covered. Typically, a regular comprehensive oculo-visual assessment (eye exam) can cost anywhere between $100-350. The specific price can vary significantly depending on:
- The clinic in question
- The expertise of your optometrist
- The available on-site equipment
- The type of eye exam being performed (basic exams are less expensive while comprehensive medical tests are more expensive)
- Whether or not you require any additional specific testing
- The nature of the practice where the optometrist is working
It helps to check in with your optometrist ahead of time. They can discuss your options to make sure that the eye care you need is within reach.
How Often Should You Have an Eye Exam?
Regardless of your age, you should be visiting your optometrist at least once per year for a comprehensive eye exam. This isn’t just about checking your vision or getting a new prescription; it’s about monitoring potential changes in your eyes and addressing problems long before they damage your eyesight.
Plenty of conditions, like diabetes or even high blood pressure, can damage your eyes permanently. However, these same conditions are also easily detectable by an eye exam. Don’t put your vision at risk; your optometrist can catch these potential problems before you experience loss of vision.
Is It Time for Your Next Eye Exam?
When it comes to eye health, a proactive approach is key—and here at View Eye Care, we can help. Contact our team for any of your eye care needs; we’re here to keep your eyes healthy and your vision clear. Book your next appointment with us today!
