Optometrists are detecting more than eye disease but vision care coverage isn’t keeping up
Vision care in Canada’s group benefits landscape may be shifting but not quickly enough, according to the latest findings from the Canadian Association of Optometrists (CAO) 2025 Vision Care Survey.
The survey, which gathered responses from 60 participants across insurers, advisors, and plan sponsors, shows clear pressure to modernize coverage for diagnostic tools, recall exams, and progressive lenses amid growing concern that many benefits plans no longer reflect the clinical or economic realities of modern optometry.
According to Denise Balch, president at Connex Health, the goal was to uncover not just what current vision benefits include, but how stakeholders perceive their value, particularly in terms of prevention, and where they see room for change.
“The good news is that vision care benefits are important to 88 per cent of respondents,” Balch said in a webinar on Tuesday. “When we asked how important vision care benefits are, everybody who participated said they’re important and that’s good news.”
Balch was quick to highlight the uptick in insurer satisfaction with their current vision care offerings, adding that some insurers have made changes to their offerings, particularly increases to maximums for comprehensive exams and frames and lenses and were often in response to plan sponsor or member demand.
Yet, she raised concerns about the inconsistent and often unclear approach insurers take when setting reasonable and customary (R&C) allowances for vision care benefits. She noted that while many assume these limits are based on actual submitted claims, that’s not always the case.
“It’s always been my impression that reasonable and customary allowance is reflective of the claims that are received by the insurer,” she said.
Still, survey responses showed significant variance in R&C maximums for comprehensive exams and diagnostics, ranging from under $100 for smaller groups to upwards of $250. Balch pointed out that while the CAO recommends a range of $200 to $250 every 24 months to account for modern diagnostics, many payers fall below that threshold.
She emphasized the lack of a standardized fee schedule for optometrists, unlike dental care, which further complicates benefit design.
“In some regions, the allowance of $200 to $250 is more than enough,” she said, adding that in high-cost urban areas like Toronto or Vancouver, exam fees often exceed those figures.
The survey revealed that insurers use different approaches to set these allowances. Some base them on previous claims, others on fixed maximums, and in some cases, they’re set by the plan sponsor. Still, in many cases, plan members end up paying out of pocket for essential care, she added.
While the survey confirmed that vision care benefits are beginning to evolve, with a clear trend toward expanding coverage, Balch believes progress is still uneven. Notably, nearly 75 per cent of payers reported increasing the maximums for eye exams over the past year. Balch called this “encouraging and consistent with CAO’s advocacy efforts.”
Some insurers also boosted coverage for frames and lenses, a more common adjustment, but there were fewer who addressed gaps in recall or partial exam allowances. Only one payer added or increased coverage for progressive lenses, though Balch noted that’s still an improvement from 2024.
Looking ahead, insurers appear open to further updates. According to Balch, one carrier told CAO it plans to conduct a full review of its vision care offerings in 2026 while others expressed interest in expanding support for diagnostic imaging and follow-up exams between comprehensive visits.
Balch underscored that better communication and education around eye exams and diagnostics could help solve some of vision care’s critical issues; not just for plan sponsors and advisors, but for plan members themselves, adding that a more informed consumer base would help drive more balanced benefit decisions.
Optometry is essential
Dr. Allison Scott, president of the CAO, stressed that optometry is increasingly playing a broader role in the healthcare system. Not just in detecting eye disease, but in identifying signs of systemic conditions during routine exams.
“We’re not just talking about eye disease. We can find signs of hypertension, heart disease, diabetes,” she said, pointing to the growing importance of vision care amid a national shortage of general practitioners.
“There are also times that we have been the first person to find someone’s MS… Similarly, brain tumors can show up in visual symptoms first,” she added.
She explained that optometrists are often the first point of contact for serious health issues. Autoimmune conditions like Crohn’s disease or arthritis can also present through inflammation in the eye before any other symptoms become obvious.
Patients often downplay or ignore early warning signs, Scott noted, assuming their discomfort is normal. But to trained optometrists, subtle changes can indicate much larger health issues. While she acknowledged that cataracts are a common part of aging and generally treatable, she highlighted more serious chronic conditions like macular degeneration, glaucoma, and diabetic retinopathy as major concerns requiring early detection and ongoing care.
Macular degeneration, which already affects an estimated 2.5 million Canadians, targets central vision and can be severely life-altering. As Canada’s population ages, she warned this condition will become more prevalent, potentially threatening individuals’ ability to live independently, work, or drive.
Glaucoma, by contrast, develops slowly and often without symptoms, affecting peripheral vision first and makes it harder for employees to detect. While glaucoma is typically manageable with drops or laser treatment, success hinges on catching it before damage is done.
“The earlier we can detect the disease, the better shot we’re giving that person to continue to see throughout their lifetime,” she said.
Scott also pointed to a surge in conditions like dry eye and myopia, which are increasingly linked to extended screen time and leads to dryness, itchiness and fatigue.
Additionally, she noted that watery eyes, a common complaint, is often misunderstood because excessive tearing is actually a reflex response to dryness. Tear quality matters just as much as tear quantity, and poor oil production from meibomian glands, responsible for the protective oil layer in tears, is a major contributor. Without it, tears evaporate too quickly.
New diagnostic tools allow optometrists to measure gland function, tear composition, and inflammation. These insights help guide personalized treatment using technologies like ILUX, LipoFlow, RF, and IPL therapies.
She believes expanded scope could help alleviate pressure on the Canadian healthcare system and improve outcomes, but only if insurance coverage evolves accordingly as she emphasized that “not having coverage to do the things that we can do can be a barrier,” adding that without adequate benefits, plan members may be forced to pay out of pocket or go without necessary care.
Additionally, with AI and new technologies accelerating the pace of change, Scott said more frequent testing and treatments are becoming standard particularly for conditions like glaucoma, which may require two to four visits annually.
She also pointed to procedures like eyelid lesion removal and even blood testing as areas where optometrists could step in to fill healthcare gaps.
“It’s a big space and there’s a lot of options. Optometrists continue to change, but hopefully the benefits plan can continue to change with them,” she said.
