Ontario Disability Support Program - Income Support Directives | Ministry of Community and Social Services

9.14 - Vision Care Benefits

Summary of Legislation

Costs approved by the Director for vision care services (e.g. glasses) are covered for eligible members of the benefit unit, excluding dependent adults. Dependent adults may access vision care services as a discretionary benefit through Ontario Works.

Routine eye exams by optometrists/ physicians are covered once every 24 months where not covered by OHIP for eligible members of the benefit unit, including dependent adults.

Legislative Authority

Section 44(1)ii; 44(1)1.1(a) and (b); 44(8); 45(1), (2), (3) of the ODSP Regulation

Summary of Directive

All eligible persons are entitled to a new pair of frames and lenses every 3 years, if requested.

Children may receive replacement lenses and/or frames as needed without restrictions.

All members of the benefit unit are entitled to coverage of routine eye examinations once every 24 months where not covered by OHIP.

Intent of Policy

To ensure that eligible members of the benefit unit are provided with routine eye examinations where they are not otherwise covered by OHIP and prescribed vision care at no cost.

Application of Policy

Coverage of Eye Examinations - OHIP

The Ontario Health Insurance Plan (OHIP) will pay for eye examinations:

For OHIP eligible persons under the age of 20 years or 65 years and over; or
For OHIP eligible persons between the age of 20 and 64 years who have medical conditions requiring a major eye examination, (i.e., treatments for infection, disease and injury). OHIP covers a major eye exam for these recipients once every 12 months.

Coverage of Eye Examinations - ODSP

If an eye examination is not otherwise covered by OHIP, an ODSP recipient/ member of the benefit unit is eligible for a routine eye examination once every 24 months under ODSP.

Confirming ODSP Eligibility for Routine Eye Exam (Periodic Oculoviaual Assessment)

Recipients are required to provide the optometrist or physician with their health card and Ministry drug card at the time of the examination.

Recipients who are not eligible for OHIP and therefore have no OHIP card, will only need to provide the optometrist or physician with a drug card.

Billing for Eye Examinations Covered Under ODSP

The Ministry of Health and Long-Term Care (MOHLTC) administers the eye examination claims and payment processing for eligible ODSP recipients. The cost is covered 100% by the province.

Note: If an issue arises related to payments for eye examinations and prescriptions, the issue should be addressed by MOHLTC.

Standard Vision Care Benefits

Standard vision care benefits are available to:

All members of the ODSP benefit unit with the exception of dependent adults (dependent adults may be eligible for discretionary services under Ontario Works);
ODSP recipients who are eligible for Extended Health Benefits;
Recipients of Assistance for Children with Severe Disabilities (ACSD); and,
Persons eligible for the Transitional Health Benefit.

Vision care services are administered through MOHLTC. The Ministry of Community and Social Services is billed monthly by MOHLTC via a journal entry. The journal entry includes the cost for the item and the administration of the service.

Note: There may be situations where an ODSP recipient, who is a refugee claimant under the Immigration and Refugee Protection Act requests vision care. Some refugees may be eligible for the Interim Federal Health Program, which covers some vision care.

In situations such as these, staff should ensure that the recipient is not eligible for these benefits through the Interim Federal Health Program prior to issuing the benefit.

Vision Care Benefits That May be Authorized

Standard Benefit	All eligible persons are entitled to a new pair of frames and lenses every 3 years, if requested.
Replacement due to Loss, Damage or Negligence	Adults will not receive replacement lenses and/or frames due to loss, damage, or negligence; however some exceptions may be permitted (see Special Circumstances) Children may receive replacement lenses and/or frames as needed without restrictions; however, cases are subject to review where abuse is detected.
Replacement Lenses due to a change in Prescription	Adults may receive new lenses only when there is a significant change in prescription. A significant change in prescription is defined as a change in refractive error of not less than 0.5 diopter to the spherical or cylinder lens, or a change in axis equal to or greater than: 20 degrees for a cylinder lens of 0.50 diopters or less; 10 degrees for a cylinder lens of more than 0.50 diopters but not more than 1.0 diopter; and degrees for a cylinder lens of more than 1.0 diopter. Children are entitled to new lenses anytime there is a change in prescription. Note: The new lenses should be placed in existing frames; where possible. However, where necessary, new frames may be authorized as well.
Repairs	Authorization is required and members of the benefit unit must show proof of need (e.g. broken glasses). Optometrists and opticians will be authorized to repair glasses (whether originally purchased under the Vision Care Benefit or not) in cases where the cost of repairs will not exceed the cost of replacement. There is no frequency limitation on authorized repairs for adults or children.
*Choice of Lenses and/ or Frames*
Lenses	Although there are some limits regarding bifocal lenses, the lenses required are usually dictated by the prescription. A member of the benefit unit may choose more expensive lenses (tints, photogray) and pay the difference in cost including the difference in dispensing fee directly to the supplier. In cases where the item is a medical necessity, it may be authorized (see Special Circumstances).
Frames	Under the ODSP Vision Care Benefit, frames are provided subject to a maximum amount. A member of the benefit unit may choose a more expensive frame and pay the difference in cost directly to the supplier.
*Special Circumstances*
Replacement for Adults	Where a member of the benefit unit has lost or damaged glasses through no fault of his/her own, ODSP staff may authorize replacement and provide written rationale.
Special Lenses and/ or Frames	Where a member of the benefit unit has special requirements or needs (special frames and/or lenses) for medical reasons, the item or service may be authorized with appropriate verification. Special lenses and/or frames may be authorized after receiving documentation from the prescribing Ophthalmologist, Optometrist, or Physician explaining the necessity of the service or item. The dispensing Ophthalmologist, Optometrist, Optician or Physician must provide an authorization letter stating medical necessity along with the Authorization/Payment form to receive payment. If the request is over $300 or is for something that is not listed in the fee schedule, the Ministry of Health and Long-Term Care requires a letter from ODSP staff authorizing the request in addition to the authorization form and physician's letter.
Contact Lenses	As a general rule, ODSP will not pay for contact lenses. If there is a situation where contact lenses are considered a medical necessity, written clinical rationale along with the prescription are to be submitted to ODSP staff. Medical necessity consists of the following conditions: corneal abnormalities; astigmatism; high refractive error where the error is greater than 8 diopters; and, Anisiometropia.
Eye Examinations	The drug card and health card are to be used to confirm ODSP eligibility at the time of examination. Where the recipient does not have a health card (ineligible for OHIP), the drug card can be used to confirm ODSP eligibility. Coverage: 20 to 64 yrs. - recipient is covered for eye examinations through ODSP under 20 yrs or 65 yrs and over -covered by OHIP. 20 to 64 years with medical condition - covered by OHIP.