Download Income Support Directive 9.14

Ontario Disability Support Program - Income Support
Directives
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.
October 2015
Page 1 of 7
•
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 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.
October 2015
Page 2 of 7
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.
October 2015
Page 3 of 7
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.
October 2015
Page 4 of 7
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 of
ODSP.
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:
•
A copy of the Authorization/Invoice for Vision Care (Form 7730-1036)
•
A completed Vision Care Benefit (Exceptional Circumstances) (Form
3183E 2014/11) including:
o Description of item(s)/service(s) being requested;
o Cost of the item(s)/service(s) being requested; and,
o Clinical rationale and diagnosis for the requested item(s)/service(s).
October 2015
Page 5 of 7
The Vision Care Benefit (Exceptional Circumstances) (Form 3183E 2014/11) is
available online to service providers on the Ontario Shared Service Forms
repository web portal:
http://www.forms.ssb.gov.on.ca/ (search for Form 3183E)
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.
The 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 the following link on the MOHLTC’s website at:
http://www.health.gov.on.ca/en/public/programs/adp/
Hyperlinks associated with this policy directive
Related Directives:
9.6 Assistive Devices
October 2015
Page 6 of 7
9.10 Extended Health Benefit
9.19 Transitional Health Benefit
ODSP Policy Bulletin:
2004-08
October 2015
Page 7 of 7