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This fact sheet provides basic information for health care providers and the public and should not be construed as legal advice. The authoritative source for OHIP eligibility is the Health Insurance Act and Reg. 552 thereunder.
Cataract and Lens Exchange Surgeries
What OHIP Covers
Cataract and intraocular lens exchange surgeries are insured under OHIP.
OHIP coverage includes the lens that the patient's physician determines is medically necessary for the individual patient at the time of the surgery.
An insured person is entitled to receive these services without charge regardless of the type of facility or setting in which the services are provided.
No amount may be charged to the patient for the medically necessary lens or eye tests, or for other necessary add-ons to the insured services, such as premises, equipment, supplies and personnel that are required to provide the service.
A physician might offer patients:
- lenses with features that are not medically necessary, such as multi-focal lenses to correct refraction
- tests that are not medically necessary or for which there is a comparable insured test
The physician must discuss all uninsured services with the patient and give the patient the option of receiving medically necessary tests and lenses without charge.
When a patient makes a voluntary choice to purchase a lens with features that are not medically necessary, the ministry requires that the patient receives a credit for the cost of the medically necessary lens that should appear on the invoice.
Access to insured cataract and lens exchange surgery and tests cannot be made conditional on a person's decision to pay for uninsured services such as eye tests or a lens with features that are not medically necessary.
The Ontario Health Technology Advisory Committee published a report that identified lenses that do not provide a significant clinical advantage. For more information, please refer to the Ontario Health Technology Advisory Committee Recommendation "Intraocular Lenses for the Treatment of Age-Related Cataracts", October 2009, which is available on the ministry website at www.health.gov.on.ca.
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