A Guide to OHIP Eye Exam Coverage

OHIP (Ontario Health Insurance Plan) is the provincial health care plan funded by the Government of Ontario which covers many health expenses including eye exams. OHIP eye exam coverage is not universal, nor is it particularly straightforward. This article will be your guide to OHIP eye exam coverage.

Who Should Know About OHIP Eye Exam Coverage?

If you are studying to enter the eye care field, as either an Optometrist, an Optician, an assistant, or a receptionist, you are sure to work with OHIP in one way or another. You might need to; verify a patient’s eligibility to use the services, submit a claim for payment, enter data into your patient-management-system, and answer common questions from patients or potential clients. So, it pays to know how OHIP eye exam coverage works.

Services Available through OHIP Eye Exam Coverage

In general, OHIP covers three main services, including major eye exam, minor eye exam, and visual field assessment for individuals who meet the eligibility criteria. Also, the Ontario Ministry of Health and Long-term Care defines the scope of each of these services, let’s take a look;

Major Eye Exam

Also referred to as Routine or Periodic Oculo-Visual Assessment, or Comprehensive Eye Exam. A major eye exam is a complete examination of the health of the eye and its structure, plus refraction.

Minor Eye Exam

Also known as Oculo-Visual Minor Assessment, or Partial Eye Exam. A minor assessment could be any eye problem such as eye infections, allergic eye reactions, eye injuries, etc.

Visual Field (VF) Assessment

Automated Visual Field assessment is done using an instrument called a perimeter, and it maps out the extent of a person’s field of view. An OHIP-covered VF assessment is usually done when the optometrist finds suspicious or alarming signs during a major assessment.

Eligibility Criteria

What Will You Need?

Anybody seeking an OHIP covered eye exam must provide a valid Ontario health card at the time of the exam.

For whom does OHIP cover eye exams?

Children – 0 to 19 Years Old

Children aged 19 and under are eligible for;

• A comprehensive eye exam once every 12 consecutive months (once per year).

• Any required minor assessments throughout the year.

Note: A prescription check is only covered once per year during the comprehensive eye exam.

Seniors – 65 Years and Over

Seniors 65 years old and over are eligible for;

• A comprehensive eye exam once every 12 consecutive months (once per year).

• Any required minor assessments throughout the year.

Note: A prescription check is only covered once per year during the comprehensive eye exam.

Adults- 20 to 64 Years Old

Adults between the ages of 20 to 64 do not have OHIP eye exam coverage unless;

• They have been referred to the optometrist by a primary healthcare professional (i.e. physician, or a registered nurse). The referring doctor must complete a Request For Major Eye Examination form and the patient must take this form to the optometrist,

Note: In this case, the person is eligible for one major assessment and one minor assessment related to the initial chief complaint per year for 5 years.

• They receive financial aid from ODSP (Ontario Disability Support Program) or OW (Ontario Works),

Note: Individuals receiving ODSP or OW benefits are eligible for OHIP covered eye exam once every 24 consecutive months (once every 2 years).

• They have been diagnosed with one of the 10 conditions listed below;

Note: In this case, the person is eligible for 1 major eye exam once every 12 consecutive months, plus necessary minor exams (follow-ups).

Optometry Fee Schedule

The Ontario Ministry of Health and Long-term care has defined a fee schedule for OHIP eye exam services. The fee schedule is a guide for eye care professionals that outlines the amount payable to the optometrist for OHIP-covered eye exams. It also assigns a unique code to each service and eligibility criteria.

Fee Code	Service	Age Group(s)
V402	Minor Assessment	19 & under, and 65 & over
V404	Major Assessment	19 & under
V406	Major Assessment	65 & over
V408	Minor Assessment	20-64 (conditional upon V409)
V409	Major assessment	20-64 (Conditional)
V410	VF Assessment	Conditional upon V404, V406 & V409
V450	Major assessment	20-64 Receiving ODSP Benefits
V451	Major assessment	20-64 Receiving OW Benefits

Common Questions about OHIP that We Have Heard from Clients