Ontario Disability Support Program - Income Support …

1 November 2014 Page 1 of 6 Ontario Disability Support Program - Income Support Directives 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) 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.

2 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 ( , treatments for infection, disease and injury). OHIP covers a major eye exam for these recipients once every 12 months.

3 Ophthalmic examinations conducted or interpreted by an Ophthalmologist for OHIP eligible persons of any age who have medical conditions November 2014 Page 2 of 6 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.

4 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. 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) November 2014 Page 3 of 6 Children receiving Assistance for Children with Severe Disabilities (ACSD) Frequency and Limits All eligible beneficiaries are entitled assistance with the cost of new lenses and frames every 3 years, when necessary.

5 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.

6 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 Replacement of Lenses Due to Change in Prescription Lens Replacements are not a standard benefit but rather based on need. If the replacement period 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.

7 A significant change in prescription is defined as a change in refractive error of not less than diopter to the sphere or cylinder power, or a change in axis equal to or greater than: 20 degrees for a cylinder power of diopters or less; November 2014 Page 4 of 6 10 degrees for a cylinder power of more than diopters but not more than diopter 5 degrees for a cylinder power of more than 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.

8 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.

9 Exceptional Circumstances 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 MCSS before providing Exceptional Circumstances services to recipients. Decisions on Exceptional Circumstances requests will be made by the Director of ODSP Branch. Decisions take into account recommendations of the Medical Advisory Unit (MAU) of the ODSP Branch. The service provider must provide the following information: A copy of the Vision Care Authorization Form Completed Exceptional Circumstances Form including: November 2014 Page 5 of 6 o Description of item/service being requested, and o Clinical rationale for additional service, and o Cost of the item/service being requested.

10 Service providers must send their claim form to: Ministry of Community and Social Services Medical Advisory Unit 80 Grosvenor Street, 3rd Floor, Hepburn Block Toronto, ON M7A 1E9 Clients should be advised that the service provider must obtain pre-authorization for items outside the schedule prior to providing the service. MCSS will notify the service provider of the approval. If there is not sufficient information provided to make an informed decision, a letter is sent to the service provider requesting additional information or explanation. If a response if not received within 2 weeks of the request for additional information a follow-up call is made to the service provider.