Optometry Insurance Coverage Details | MSP 2023 Update

Copy from the BC MSP Guidelines:

Routine eye examinations are not an MSP benefit for individuals aged 19 to 64 years. Medically required eye examinations continue to be a benefit for all MSP beneficiaries. We are providing the following information to clarify the changes to the eye examination benefits and to provide more detail on when a referral is required.

According to Optometry Insurance Coverage with MSP, an eye examination is an insured benefit if medically required. The diagnoses which meet the MSP definition of medically required are listed by ICD9 code, and are payable at the frequency indicated on the website. In general, the criteria for medically required Optometry Insurance Coverage includes:

• ocular disease, trauma or injury
• systemic diseases associated with significant ocular risk (e.g. diabetes)
• medications associated with significant ocular risk

Formal referrals to ophthalmologists or direct requests to optometrists for an eye examination on behalf of patients are appropriate only if, in the practitioner’s judgement, and based on clinical evidence, there is a medical necessity for the examination.

Refractive change (needing glasses or contact lenses) with no other pathology does not meet the MSP medically required criteria for payment. These patients should contact their optometrist directly to request an eye exam and they should also be advised that payment for the eye examination would be their responsibility.

MSP will be monitoring billings and conducting audits of referrals to assess compliance with the criteria defining medically required services.