Bulletin 230902 — Changes to OHIP insured optometry services
Update to physicians on changes to the Schedule of Benefits for Optometry Services
To: All Physicians
Category: Physician Services
Written by: Provider Services Branch, Physician and Provider Services Division
Date issued: August 31, 2023
Bulletin Number: 230902
Background
The Ministry of Health (ministry) and the Ontario Association of Optometrists (OAO) have a new Optometry Services Agreement (Agreement) for the period of April 1, 2021 to March 31, 2025, as published in INFOBulletin 230311.
Changes to OHIP insured eye exams provided by optometrists, as listed in the Schedule of Benefits for Optometry Services, including medical eligibility and service descriptions will be effective September 1, 2023, and may impact patients under your care.
Please note that there have been no changes to the Schedule of Benefits for Physician Services as a result of these negotiations.
September 1, 2023 Changes to the Schedule of Benefits for Optometry Services
Changes to OHIP insured eye exams for adults 20 to 64 years of age as well as for seniors aged 65 or more will be implemented on September 1, 2023.
Major oculo-visual eye examinations:
Adults 20 to 64 years of age
Eligibility requirements for major oculo-visual eye examinations for patients aged 20 to 64 have changed.
Referrals to an optometrist using fee code E077A (identification of patient for a major eye examination) in the Schedule of Benefits for Physician Services no longer result in an insured optometrist eye exam.
Patients may continue to receive an insured physician major eye examination if a physician refers to another physician using the E077A requisition form.
Patients aged 65 years or more
Seniors with an eligible medical condition may continue to receive an OHIP insured major oculo-visual eye examination from an optometrist every 12 months.
New: seniors without an eligible medical condition will only be eligible for an insured major oculo-visual eye examination from an optometrist every 18 months.
Oculo-visual minor assessments for all adults 20 years of age and older
Patients 20-64 (with an eligible medical condition) are eligible for a maximum of two OHIP insured minor assessments within the 12-month period following an insured major oculo-visual examination from an optometrist.
All patients 65 years of age and older are eligible for a maximum of two OHIP-insured minor eye assessments from an optometrist within the appropriate eligibility period (example: 12 or 18 months as above) following an insured major oculo-visual eye examination from an optometrist.
Physician provided major eye exams
The eligibility period for an OHIP insured major eye examination or periodic oculo-visual assessment (POVA) provided by a physician remains unchanged: one insured service every 12 months.
Please note, this service continues to be insured every 12 months regardless of whether the first claim in the eligibility period is submitted for a service provided by a physician or for a major oculo-visual examination provided by an optometrist.
Patients who receive a major eye examination or a POVA from a physician continue to be eligible for OHIP insured follow-up services from a physician.
Please note, these patients will not be eligible for insured minor eye assessments from an optometrist during the eligibility period if they receive a major eye examination or POVA from a physician. This includes post-operative services by an optometrist following cataract surgery by a physician.
Cataract surgical care
All post-operative cataract care is an insured service when provided by a physician. Post-operative cataract care provided by an optometrist could be uninsured if the patient has exceeded the maximum number of minor assessments within the appropriate eligibility period (example: 12 or 18 months, as above).
Keywords/Tags
OHIP insured eye exams; eye exams; 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. Hours of operation: 8:00 a.m. to 5:00 p.m. Eastern Monday to Friday, except holidays.