February 2018

9.14 Vision Care Benefits

Summary of Directive

All eligible persons may receive new lenses and frames every 3 years, when necessary.

For children, assistance with the cost of new lenses may be provided anytime there is a change in prescription.

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

Legislative Authority

Section 44(1)1.ii of the ODSP Regulation

Intent of Policy

To ensure that eligible members of the benefit unit are provided with routine eye examinations once every 24 months where they are not otherwise covered by OHIP.

To provide assistance to ODSP recipients and eligible dependants for the purchase of optical goods and services from eye care professionals.

Application of Policy

Coverage of Eye Examinations - OHIP

OHIP will pay for:

  • Routine eye examinations (oculo-visual assessment) conducted by an Optometrist or Physician for OHIP eligible persons under the age of 20 years or 65 years and over; or
  • Major eye examinations conducted by an Optometrist or Physician for OHIP eligible persons aged 20 to 64 years inclusive 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.
  • Ophthalmic examinations conducted or interpreted by an Ophthalmologist for OHIP eligible persons of any age who have medical conditions requiring an Ophthalmic examination.

Coverage of Eye Examinations - ODSP

If an eye examination is not otherwise covered by OHIP, an ODSP recipient and all member of their benefit unit, including dependent adults, are eligible for a routine eye examination once every 24 months under ODSP.

The following persons are also eligible for routine eye examinations (once every 24 months where not also covered by OHIP):

  • Clients in receipt of the Extended Health Benefit and members of their benefit unit
  • Persons eligible for the Transitional Health Benefit, their spouses and dependent children (0-17 years)
  • Children receiving Assistance for Children with Severe Disabilities (ACSD)

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

Recipients are required to provide the optometrist or physician with their health card to confirm eligibility for coverage 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 another form of identification.

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.

Vision Care Benefits

Vision care benefits are available to:

  • ODSP recipients, their spouses and dependent children (0-17 years)
  • Clients in receipt of the Extended Health Benefit, their spouses and dependent children (0-17 years)
  • Persons eligible for the Transitional Health Benefit, their spouses and dependent children (0-17 years)
  • Children receiving Assistance for Children with Severe Disabilities (ACSD)

Coverage for Lenses and Frames

All eligible beneficiaries are entitled assistance with the cost of new lenses and frames every 3 years, when necessary. For children, assistance with the cost of new lenses may be provided anytime there is a change in prescription.

MCSS Vision Care Fee Schedule

The MCSS Vision Care Fee Schedule sets out allowable amounts for lenses and frames for those eligible for eyeglasses under ODSP Vision Care Benefit.

The schedule is available to ODSP staff, participating service providers, municipal Ontario Works Administrators, and Regional Offices.

Recipients may ask their vision care service provider about the services available to them under the schedule and any limitations with respect to services they require.

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.

Replacement Lenses and Frames

Replacement of Lenses Due to Change in Prescription

Lens Replacements are not a standard benefit but rather based on need. If the replacement period (3 years) has been met, there must still be evidence of a change in correction before replacement is covered.

If the replacement period has not been met, 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 sphere or cylinder power, or a change in axis equal to or greater than:

  • 20 degrees for a cylinder power of 0.50 diopters or less;
  • 10 degrees for a cylinder power of more than 0.50 diopters but not more than 1.0 diopter;
  • 5 degrees for a cylinder power of more than 1.0 diopter.

Children may receive new lenses anytime there is a change in prescription.

Service providers must provide a letter to the caseworker indicating the change in prescription when requests for new lenses are being made.

Note: The new lenses should be placed in existing frames if the existing frames are satisfactory. If the existing frames are not satisfactory, new frames may be provided.

Replacement of Frame Due to Loss or Damage

ODSP staff may authorize a replacement where a client has lost or damaged glasses through no fault of his/her own and they are not covered under warranty. There is no frequency limitation on authorized replacements for adults or children.

Unless the eyeglasses are lost, a client must present damaged frames to ODSP staff for confirmation and approval.

If a replacement is approved, the current lenses should be placed in the new frames if the service provider determines that the existing lenses are satisfactory. If the existing lenses are not satisfactory, ODSP staff will authorize new lenses to be provided.

Exceptional Circumstances: Requests for item(s)/service(s) outside of the MCSS Vision Care Fee Schedule

A request for items outside the scope of the MCSS Vision Care Fee Schedule may be made where exceptional medical circumstances exist.

Service providers must obtain pre-authorization from the Ministry before dispensing or providing item(s)/service(s) that are outside of the fee schedule to clients. Service providers should advise clients about the pre-authorization requirement for item(s)/service(s) outside of the fee schedule.

Decisions for Exceptional Circumstances requests will be made by the Director and managers of the Social Assistance Centralized Services Branch (SACSB).

Requests for Contact Lenses

Requests for contact lenses may be considered under the Exceptional Circumstances policy in situations where contact lenses are deemed a medical necessity.

Medical necessity consists of the following conditions:

  • corneal abnormalities
  • astigmatism (only when it cannot be corrected by spectacle lenses)
  • high refractive error where the error is greater than 8 diopters
  • anisometropia
Submission of Exceptional Circumstances Requests

The service provider must submit the following:

If the information provided is not sufficient to make a decision, a letter will be sent to the service provider requesting additional information.

The service provider will have 2 weeks to respond to the request for additional information. If a response is not received within 2 weeks, a follow-up call will be made by the Ministry to the service provider.

The Ministry will notify both the client and the service provider of the decision within 30 days.

Visual Aids - Assistive Devices Program (ADP)

Persons who are unable to perform common age-related visual tasks in spite of conventional medical, surgical or routine refraction may be able to receive assistance with the cost of visual aids e.g. magnifiers, binoculars, specialized lenses.

MOHLTC’s Assistive Devices Program (ADP) pays 75% of the actual cost of ADP approved Visual Aids, up to a maximum amount.

ODSP covers the 25% consumer contribution for ODSP recipients and eligible dependants, up to the maximum amount approved under ADP.

ODSP will also pay for an assessment for an assistive device funded by ADP if there is no other source of funding for the assessment for all members of the benefit unit.

Detailed information about ADP is available under ODSP income support Directive - 9.6 Assistive Devices. Alternatively you may access MOHLTC’s website.

Related Directives

9.6 Assistive Devices
9.10 Extended Health Benefit
9.19 Transitional Health Benefit

ODSP Policy Bulletin

2004-08