FACT SHEET: What cataract surgery patients can and cannot be charged for

Posted: November 14, 2024

(November 14, 2024)

Anyone in Ontario can make a complaint or ask questions by calling toll-free at 1-888-662-6613 or by emailing protectpublichealthcare@ontario.ca.

The Ontario Health Coalition receives many complaints from patients who report being charged hundreds to thousands of dollars for medically necessary cataract surgery. This fact sheet is not legal advice but seeks to educate patients and their families about what is covered by the Ontario Health Insurance Plan (OHIP).

OHIP covers all medically necessary surgeries and diagnostics.

Under the Canada Health Act (federal legislation) and Commitment to the Future of Medicare Act (Ontario’s legislation), all medically necessary surgeries – including cataract surgery – and diagnostic tests (like lab tests, MRIs, CT scans and eye measurement tests for cataract surgery) are covered under OHIP. Patients cannot be charged for services that are covered by OHIP.

Queue jumping is prohibited.

Under the Canada Health Act and Commitment to the Future of Medicare Act, patients cannot buy their way to the front of the line, pushing other patients back. No private clinic can tell patients that they can get care faster if they pay a fee.

The following information is from the Ministry of Health:

Laser cataract surgery is covered by OHIP.

Cataract and intraocular lens exchange surgeries are covered by OHIP, regardless of how the surgery is performed (e.g., by laser or scalpel). This means that laser surgery is covered.

Purchasing medically unnecessary services cannot be a condition of receiving medically necessary health care services without extra charge.

Patients cannot be told to pay for unnecessary extra measurement tests and upgraded lenses to get the medically necessary surgery. Patients who have told us that private clinics said they had to pay for cataract surgery have shown us invoices that show the clinic billed OHIP for the surgery and charged the patient for unnecessary tests and lenses.

Physicians or clinics must provide patients with sufficient information so that they can make a voluntary informed decision.

They cannot manipulate patients into believing that they will not have good results if they get the OHIP-covered service. Cataract surgery is one of the safest surgeries with a very high success rate of 98%. Patients are often not told that “OHIP-covered” eye surgery has an extremely high rate of success and is all that they actually need. Patients cannot be told that the “OHIP-covered” surgery is unsafe or inadequate to manipulate them into paying more.

There is no “standard” lens that is the only type of lens covered by OHIP.

Physicians must assess and test all patients to determine the necessary individualized lens that the patient needs. This individualized lens is covered by OHIP. The assessments and tests done to determine the type of lens the patient needs are up to date. Extra tests are not needed.

If patients voluntarily choose to purchase added services, then they are entitled to receive credit for the cost of the medically needed service.

For example, if a patient voluntarily chooses to purchase lenses for astigmatism, then they must receive credit for the cataract surgery. The credit must appear in their invoice.

The equipment used and the personnel required to perform the surgery or service

are covered by OHIP and are not the financial responsibility of the patient.

Eye drops or ointments needed before or after cataract surgery are covered by OHIP.

The OHIP Claims Office has told the OHC that these ophthalmic drugs are covered by OHIP since they are medically needed before and after surgery. Patients have been charged over $150 for eye drops. That is not supposed to be allowed.

Click here for printable version of OHC fact sheet

Click here for the Ministry of Health’s fact sheet on what OHIP covers for cataract surgery

Click here for the Ministry of Health’s bulletin release on what OHIP covers for cataract surgery