Eye and Vision Care Benefits Information

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Questions and Answers

What Eye and Vision Care Benefits are covered by the Non-Insured Health Benefits (NIHB) Program?

• Eye examinations, when they are not insured by the province/territory (e.g. eye exams for children, elderly and diabetic clients in some provinces/territories);
• Eyeglasses that are prescribed by a vision-care provider;
• Eyeglass repairs;
• Eye prosthesis (an artificial eye); and
• Other vision care benefits depending on your specific medical needs.

How do eligible clients obtain these benefits?

• You must be examined by an optometrist or an ophthalmologist, to obtain a prescription;
• You should take the prescription to a recognized vision provider, such as an optician or an optometrist; and
• The provider must obtain pre-approval of the benefit by calling or faxing the Health Canada regional office.

Who can prescribe eligible Eye and Vision Care Benefits?

Services must be prescribed by a licensed vision care professional, such as an optometrist or ophthalmologist to be considered eligible.

Who can provide eligible Eye and Vision Care Benefits?

To be eligible for coverage, eye and vision care services must be provided by a licensed optometrist or optician.

How often will the NIHB Program cover an eye exam?

• Every 24 months for a person 18 years and over.
• Every 12 months for a person younger than 18 years.
• When there is a change or correction in vision.

However, if you have diabetes (or another medical condition) you may be eligible for a complete eye exam every 12 months.

Why does the NIHB Program cover eye examinations only every two years for adults?

It is common medical practice for eye examinations to be performed every two years for healthy individuals with no underlying conditions. The NIHB Program may cover follow-up examinations when medically necessary, for example in cases with an underlying medical condition, such as diabetes.

Are eyeglass repairs covered by the NIHB Program?

Yes, under the following conditions:

• The total cost of the repair cannot exceed the cost to replace the eyeglasses; and
• Only one major repair and one minor repair are covered within the eyeglasses replacement time frame (12 or 24 months).

Please note that replacement frames or sets of lenses are not eyeglass repairs. Replacements or repairs as a result of misuse, carelessness or negligence are not covered by the NIHB Program.

What Eye and Vision Care items or services are not covered by the NIHB Program? (Exclusions)

The following is a list of some (but not all) excluded items:

• Vision care goods and services covered by provincial/territorial health insurance plans
• Esthetic products;
• Vision exams required for a job, drivers license or to engage in sports activity;
• Safety glasses for sport, leisure or work use;
• Implants (e.g. punctual occlusion procedure); and
• Laser surgery

Is there an appeal process when a benefit has been denied?

A client, parent, legal guardian or representative may initiate an appeal when an eligible benefit has been denied by the NIHB Program.

For a case to be appealed, a signed note or letter from the client, parent or legal guardian, accompanied by supporting information from the service provider or prescriber (e.g. doctor) must be submitted to the NIHB Program. There are three levels of appeal available.

Information on the appeal process is available on the Health Canada Website or contact the Health Canada regional office to that effect.

Where can I get more information about the NIHB Eye and Vision Care Benefit?

For more information, please contact the Health Canada regional office nearest you.

For more information regarding this benefit, please consult the Benefit information page on the Health Canada Website.

How do I contact the Health Canada regional office in my area?

A complete list of Health Canada regional offices is available on the Health Canada Website.

Resources

• Vision Care Framework
  The Non-Insured Health Benefits Vision Care Framework clearly defines the benefits and criteria associated with the provision of vision care benefits to NIHB recipients.
• NIHB Eye and Vision Products and Services Prior Approval and Claims Form
  When requesting funding for vision care benefits to the Non-Insured Health Benefits (NIHB) Program, providers may use the NIHB Eye and Vision Products and Services Prior Approval and Claims Form.

  The form information is available in HTML and Portable Document Format (PDF). The HTML version of the NIHB Eye and Vision Products and Services Prior Approval and Claims Form is not an actual form. It displays the information found on the form for viewing purposes only and will not be accepted if used to request funding.

Visit the Reports and Publications section to access a wide variety of Non-Insured Health Benefits documents.