ALBERTA HEALTH CARE INSURANCE ACT ALBERTA HEALTH CARE INSURANCE ACT
Chapter A‑20
Table of Contents
1 Definitions
2 Insured services
Part 1 Health Care Insurance
3 Operation of Plan
4 Coverage under Plan
5 Change in residence
6 Payment of benefits
7 Opting in and out by dentists
8 Opting in and out by physicians
9 Extra billing
10 Emergency services
11 Other prohibited fees
12 Prohibition on receiving benefits
13 Minister’s right to recover amounts
14 Offence
15 Duty to advise
16,17 Regulations 18 Reassessment of claims
19 Order reducing future benefits
20 Remuneration of practitioners
21 Relationship between practitioner and patient
22 Disclosing health information
23 Protection from action
24 Assignment of benefits
25 Crown’s right of recovery
26 Prohibitions
27 False statements
28 Information for claim
Part 2 Optional Health Services
29 Definitions
30 Regulations
32 Regulations
Part 3 General
33 Regulations
34,35 Retrospectivity of regulations
36 Payments out of General Revenue Fund
37 Benefits review committees
38 Forms
39 Examination of practitioner’s records
39.1 Disclosure of information to prevent or limit fraud or abuse of health services
40 Special agreements
41 Blue Cross agreement
42 General penalty
43 Financial assistance
44 Residence requirements
HER MAJESTY, by and with the advice and consent of the Legislative Assembly of Alberta, enacts as follows:
Definitions
1 In this Act,
(a) “ABC Benefits Corporation” means the ABC Benefits Corporation continued under the ABC Benefits Corporation Act;
(b) “basic health services” means
(i) insured services,
(ii) those services that are provided by a dentist in the field of oral and maxillofacial surgery and are specified in the regulations but are not within the definition of insured services,
(iii) optometric services,
(iv) chiropractic services,
(v) services and appliances provided by a podiatrist,
(vi) services classified as basic health services by the regulations;
(c) “benefits” means the amounts payable by the Minister in respect of the cost of health services provided to residents;
(d) “Blue Cross agreement” means an agreement made between the Minister and the ABC Benefits Corporation pursuant to section 41;
(e) “chiropractic services” means those services provided by a chiropractor that are specified in the regulations as chiropractic services for the purposes of the Plan;
(f) “chiropractor” means,
(i) with reference to services provided in Alberta, a regulated member of the Alberta College and Association of Chiropractors who holds a practice permit respecting the practice of chiropractic or a professional corporation registered with the Alberta College and Association of Chiropractors under the Health Professions Act, and
(ii) with reference to services provided in a place outside Alberta, a person lawfully entitled to practise chiropractic in that place;
(g) “College” means the College of Physicians and Surgeons of Alberta;
(h) repealed RSA 2000 cH‑7 s144;
(i) “dentist” means,
(i) with reference to goods and services provided in Alberta, a regulated member of the Alberta Dental Association and College under the Health Professions Act who holds a practice permit respecting the practice of dentistry, and
(ii) with reference to goods and services provided in a place outside Alberta, a person lawfully entitled to practise dentistry in that place;
(i.1) “denturist” means,
(i) with reference to goods and services provided in Alberta, a person who is a regulated member of the College of Alberta Denturists under the Health Professions Act who holds a practice permit respecting the practice of denture construction, and
(ii) with reference to goods and services provided in a place outside Alberta, a person lawfully entitled to practise denture construction in that place;
(j) “dependant” means a dependant as defined in the regulations;
(k) “extended health services” means those goods and services or classes of goods and services that are specified in the regulations and provided to a resident or the resident’s dependants under section 3(2);
(l) “federal Act” means the Canada Health Act (Canada);
(m) “health services” means basic health services, optional health services and extended health services;
(n) “insured services” means
(i) all services provided by physicians that are medically required,
(ii) those services that are provided by a dentist in the field of oral and maxillofacial surgery and are specified in the regulations, and
(iii) any other services that are declared to be insured services pursuant to section 2,
but does not include any services that a person is eligible for and entitled to under any Act of the Parliament of Canada or under the Workers’ Compensation Act or any law of any jurisdiction outside Alberta relating to workers’ compensation;
(o) “Minister” means the Minister determined under section 16 of the Government Organization Act as the Minister responsible for this Act;
(p) “optician” means
(i) with reference to goods and services provided in Alberta, a person who is a regulated member of the College of Opticians of Alberta and who holds a practice permit respecting the practice of dispensing of eye glasses or contact lenses, and
(ii) with reference to goods and services provided in a place outside Alberta, a person lawfully entitled to practise opticianry in that place;
(q) “optional health services” means those goods and services or classes of goods and services that are specified in the regulations as optional health services;
(r) “optometric services” means those services provided by an optometrist that are specified in the regulations as optometric services for the purposes of the Plan;
(s) “optometrist” means,
(i) with reference to goods and services provided in Alberta, a person who is a regulated member of the optometry profession under the Health Professions Act or a professional corporation registered with the Alberta College of Optometrists under the Health Professions Act, and
(ii) with reference to goods and services provided in a place outside Alberta, a person lawfully entitled to practise optometry in that place;
(t) “physician” means
(i) with reference to medical services provided in Alberta, a regulated member of the College of Physicians and Surgeons of Alberta under the Health Professions Act who holds a practice permit issued under that Act, or a professional corporation registered with the College of Physicians and Surgeons of Alberta, and
(ii) with reference to medical services provided in a place outside Alberta, a person lawfully entitled to practise medicine or osteopathy in that place;
(u) “Plan” means the Plan referred to in section 3;
(v) “podiatrist” means,
(i) with reference to services or appliances provided in Alberta, a regulated member of the College of Podiatric Physicians of Alberta who holds a practice permit issued under the Health Professions Act, and
(ii) with reference to services or appliances provided in a place outside Alberta, a person lawfully entitled to practise podiatry in that place;
(w) “practitioner” means a chiropractor, denturist, dentist, optician, optometrist, physician or podiatrist or other person who provides a basic health service or an extended health service;
(x) “resident” or “resident of Alberta” means a person lawfully entitled to be or to remain in Canada, who makes the person’s home and is ordinarily present in Alberta and any other person deemed by the regulations to be a resident, but does not include a tourist, transient or visitor to Alberta.
(y) repealed 2003 cI‑0.5 s52.
RSA 2000 cA‑20 s1; RSA 2000 cH‑7 ss143,144,145,146,148,149,152; 2001 c10 s1;2001 c21 ss27,28;2003 cI‑0.5 s52; 2005 c13 ss1,4(4);2007 c32 s1(41);2008 c34 s18
Insured services
2 The Lieutenant Governor in Council may by regulation declare any basic health services referred to in section 1(b)(ii), (iii), (iv), (v) or (vi) to be insured services for the purposes of the Plan.
RSA 1980 cA‑24 s2
Part 1 Health Care Insurance
Operation of Plan
3(1) The Minister shall, in accordance with this Act and the regulations, administer and operate on a non‑profit basis a plan to provide benefits for basic health services to all residents of Alberta.
(2) The Minister shall, in accordance with the regulations, provide extended health services to a resident and the resident’s dependants if
(a) the resident or the resident’s spouse or adult interdependent partner is 65 years of age or older, or
(b) repealed 2003 cI‑0.5 s52.
(3) The Minister is the public authority responsible for the administration and operation of the Alberta Health Care Insurance Plan.
RSA 2000 cA‑20 s3;2002 cA‑4.5 s16;2003 cI‑0.5 s52
Coverage under Plan
4(1) Subject to this Act and the regulations, the Minister shall pay benefits in respect of health services provided to residents.
(2) All claims for benefits are subject to assessment and approval by the Minister and the amount of the benefits to be paid and the person to whom the benefits are to be paid shall be determined in accordance with the regulations.
(3) A resident is not entitled to the payment of benefits in respect of health services provided to the resident if the resident is
(a) a member of the Canadian Forces,
(b) repealed 2013 c4 s1,
(c) a person serving a term of imprisonment in a penitentiary as defined in the Corrections and Conditional Release Act (Canada), or
(d) a resident who has not completed the waiting period prescribed by the regulations.
(4) The Minister may withhold payment of benefits for health services until the Minister is satisfied that the person was a resident at the time the services were provided.
(5) For the purposes of subsection (4), a certificate of registration under the Health Insurance Premiums Act is proof, in the absence of evidence to the contrary, that the person is a resident if the certificate was in effect at the time the service was provided to that person.
RSA 2000 cA‑20 s4;2013 c4 s1
Change in residence
5(1) Subject to the regulations, a person who ceases to be a resident of Alberta and becomes a resident of any other place remains entitled to benefits for health services provided to that person during the period prescribed in the regulations.
(2) A resident does not cease to be entitled to benefits by reason of being temporarily absent from Alberta.
RSA 1980 cA‑24 s5;1983 c32 s1;1984 c26 s1
Payment of benefits
6(1) No physician or dentist may receive the payment of benefits from the Minister for insured services provided in Alberta to a resident unless the physician or dentist was opted into the Plan when the insured services were provided.
(2) No resident may receive the payment of benefits from the Minister for insured services provided in Alberta to the resident by a physician or dentist unless the physician or dentist who provided the insured services was opted into the Plan when the insured services were provided.
(3) Notwithstanding subsections (1) and (2), the Minister may pay benefits for insured services provided in Alberta to a resident by a physician or dentist who was opted out of the Plan if the insured services were provided in an emergency.
1994 c2 s3;1998 c31 s2;1999 c32 s2
Opting in and out by dentists
7(1) Subject to this section, every dentist is deemed to have opted into the Plan.
(2) A dentist may opt out of the Plan by
(a) notifying the Minister in writing indicating the effective date of the opting out,
(b) publishing a notice of the proposed opting out in a newspaper having general circulation in the area in which the dentist practises, and
(c) posting a notice of the proposed opting out in a part of the dentist’s office to which patients have access
at least 30 days prior to the effective date of the opting out.
(3) A dentist who has not previously practised in Alberta may opt out of the Plan prior to commencing practice by
(a) notifying the Minister in writing indicating the date on which the dentist will commence opted‑out practice, and
(b) publishing a notice of the proposed opting out in a newspaper having general circulation in the area in which the dentist intends to practise.
(4) A dentist who has opted out of the Plan shall
(a) post a notice in a part of the dentist’s office to which patients have access advising patients of the dentist’s opted‑out status, and
(b) ensure that each patient is advised in person of the dentist’s opted‑out status before any service is provided to the patient.
(5) A dentist who has opted out of the Plan may opt into the Plan by notifying the Minister in writing at least 30 days prior to the effective date of the opting in.
1986 c3 s2;1994 c2 s4;1998 c31 s2;1999 c32 s2
Opting in and out by physicians
8(1) Subject to this section, every physician is deemed to have opted into the Plan.
(2) A physician may opt out of the Plan by
(a) notifying the Minister in writing indicating the effective date of the opting out,
(b) publishing a notice of the proposed opting out in a newspaper having general circulation in the area in which the physician practises, and
(c) posting a notice of the proposed opting out in a part of the physician’s office to which patients have access
at least 180 days prior to the effective date of the opting out.
(3) A physician who has not previously practised in Alberta may opt out of the Plan prior to commencing practice by
(a) notifying the Minister in writing indicating the date on which the physician will commence opted‑out practice, and
(b) publishing a notice of the proposed opting out in a newspaper having general circulation in the area in which the physician intends to practise.
(4) A physician who has opted out of the Plan shall
(a) post a notice in a part of the physician’s office to which patients have access advising patients of the physician’s opted‑out status, and
(b) ensure that each patient is advised in person of the physician’s opted‑out status before any service is provided to the patient.
(5) A physician who has been opted out of the Plan for a continuous period of at least one year may opt into the Plan by notifying the Minister in writing at least 30 days prior to the effective date of the opting in.
(6) A physician who has been opted out of the Plan for a continuous period of less than one year may apply to the Minister to opt into the Plan.
(7) An application under subsection (6) must be in a form acceptable to and contain the information required by the Minister.
(8) In making a decision on an application under subsection (6), the Minister shall take into consideration the factors, if any, that are set out in the regulations.
1998 c31 s2
Extra billing
9(1) No physician or dentist who is opted into the Plan who provides insured services to a person shall charge or collect from any person an amount in addition to the benefits payable by the Minister for those insured services.
(2) If a physician or dentist contravenes subsection (1), the Minister may,
(a) in the case of a first or subsequent contravention, send a written warning to the physician or dentist,
(b) in the case of a 2nd or subsequent contravention, refer the contravention to the College or the Alberta Dental Association and College, as the case may be, and
(c) in the case of a 3rd or subsequent contravention, order that, after a date specified in the order, the physician or dentist is deemed to have opted out of the Plan for the period specified in the order.
(3) An order under subsection (2)(c) shall, prior to the effective date of the order, be served personally or by registered mail on the physician or dentist affected by the order.
RSA 2000 cA‑20 s9;RSA 2000 cH‑7 s145;2005 c13 s1
Emergency services
10 If a physician or dentist who is opted out of the Plan provides insured services in Alberta in an emergency to a resident in respect of whom benefits may be paid and the physician, dentist or resident is paid benefits with respect to those insured services, the physician or dentist shall not charge or collect from any person an amount in addition to those benefits.
1994 c2 s5;1998 c31 s4;1999 c32 s2
Other prohibited fees
11(1) No person shall charge or collect from any person
(a) an amount for any goods or services that are provided as a condition to receiving an insured service provided by a physician or dentist who is opted into the Plan, or
(b) an amount the payment of which is a condition to receiving an insured service provided by a physician or dentist who is opted into the Plan
where the amount is in addition to the benefits payable by the Minister for the insured service.
(2) Subsection (1) does not prohibit the charging or collecting of an amount paid for non‑insured health or pharmaceutical goods or services where the charging or collecting of that amount is not otherwise prohibited under this Act or the Hospitals Act and a physician or dentist reasonably determines that it is necessary to provide the non‑insured health or pharmaceutical goods or services before the insured service is provided.
(3) If a person receives an amount in contravention of subsection (1), the Minister may recover that amount in a civil action in debt as though that amount were a debt owing from the person to the Crown in right of Alberta.
(4) Where the Minister recovers any amount under subsection (3), the Minister shall reimburse the person who was charged the amount.
1998 c31 s5;1999 c32 s2
Prohibition on receiving benefits
12(1) A physician or dentist who is opted into the Plan and provides insured services to a person in circumstances where the physician or dentist knows or ought reasonably to know that the person is being charged an amount in contravention of section 11 shall not receive the payment of benefits from the Minister for those insured services.
(2) Section 9(2) applies where a physician or dentist contravenes subsection (1).
1998 c31 s5;1999 c32 s2
Minister’s right to recover amounts
13(1) If a physician or dentist
(a) in contravention of section 9 or 10, receives an amount in addition to the benefits payable by the Minister, or
(b) receives the payment of benefits in contravention of section 12,
the Minister may act under subsection (2).
(2) If subsection (1) applies, the Minister may recover the additional amount and the benefits in a case referred to in subsection (1)(a), or the benefits in a case referred to in subsection (1)(b), by one or more of the following means:
(a) by withholding those amounts from any benefits payable to the physician or dentist;
(b) by civil action as though those amounts were a debt owing to the Crown in right of Alberta;
(c) pursuant to any agreement between the Minister and the physician or dentist that provides for the repayment of those amounts.
(3) The Minister shall reimburse a person in respect of whom benefits may be paid for any amounts recovered under this section that were paid by the person and have not been previously reimbursed.
1994 c2 s5;1998 c31 s6;1999 c32 s2
Offence
14 A person who contravenes section 9, 10, 11 or 12 is guilty of an offence and liable to a fine of not more than
(a) $10 000 for the first offence, and
(b) $20 000 for the 2nd and each subsequent offence.
1998 c31 s7;2000 cH‑3.3 s31
Duty to advise
15(1) Prior to providing insured services in Alberta to a resident in respect of whom benefits may be paid, a physician or dentist who is opted out of the Plan shall advise the resident of that fact and that the resident is not entitled to be reimbursed from the Plan for the cost of any insured services provided by the physician or dentist.
(2) This section does not apply when the insured services are provided in an emergency.
1994 c2 s5;1998 c31 s8;1999 c32 s2
Regulations
16 The Lieutenant Governor in Council may make regulations
(a) authorizing or requiring the doing of any act or thing by the Minister, or any other person, for the purpose of having the Plan meet the criteria prescribed under the federal Act or to enable the Government of Alberta to receive payment of contributions by the Government of Canada under the federal Act;
(b) deeming persons to be residents for the purposes of this Act;
(c) prescribing classes of goods and services as basic health services or extended health services;
(d) providing, in respect of benefits for any or all health services provided outside Alberta or any specified place outside Alberta, that the benefits may be paid only for services provided during a specified period of time or that the Minister is empowered in a particular case to prescribe the period in respect of which benefits may be paid;
(e) prescribing the waiting period for a person who is or becomes a resident of Alberta and in respect of which the costs of any health services provided during that period to that person are not payable as benefits;
(f) subject to section 4(2), providing for procedures for the review of any decision or the settlement of any question pertaining to the determination of
(i) the amount of benefits payable for a particular service,
(ii) whether any service is a health service or not,
(iii) whether any service provided by a physician is medically required or not, or
(iv) any other matter that affects the entitlement to benefits;
(g) providing, for the purpose of removing doubt, that
(i) any service is or is not a basic health service, extended health service or insured service, or
(ii) any particular service that may be provided by a physician is or is not medically required;
(h) prescribing the duration of periods for the purposes of section 5(1) and any conditions on which a person continues to be entitled to benefits by virtue of that subsection;
(i) providing the circumstances under which a person is or is not to be considered as temporarily absent from Alberta for the purposes of section 5(2);
(j) governing notifications under section 7 or 8;
(k) respecting the factors to be taken into consideration by the Minister in dealing with applications under section 8(6);
(l) requiring practitioners to file with the Minister the kinds of information that the regulations prescribe for the purpose of facilitating the handling, assessing and payment of claims for benefits;
(m) prescribing the times by which or the circumstances under which practitioners are required to file information pursuant to the regulations under clause (l);
(n) authorizing the Minister to withhold the payment of benefits to any practitioner until the practitioner has complied with the regulations under clauses (l) and (m);
(o) prohibiting a practitioner who submits a claim to the Minister for a benefit on behalf of a resident from submitting an account to the resident or to a Government department or agency with respect to the same health services, except when the account is for an amount in addition to the benefit and is payable under an agreement or arrangement referred to in section 21(1)(b);
(p) providing, without limiting the meaning of “residents’ or practitioners’ registration information” in section 22, that certain information relating to the registration or enrolment of residents or practitioners obtained under this Act or the Health Insurance Premiums Act is included in the meaning of “residents’ or practitioners’ registration information” in section 22;
(q) designating a person or entity with which the Minister may enter into an agreement under section 22(15)(b).
RSA 1980 cA‑24 s6;1983 c32 s1;1984 c26 s1;1986 c3 s3; 1994 c2 s6;1994 c34 s3;1998 c31 s10
Regulations
17 The Minister may make regulations
(a) respecting the rates of benefits in respect of basic health services or extended health services;
(b) respecting the manner in which benefits are to be paid and the persons to whom benefits are to be paid, the conditions of payment and the information required to be submitted in connection with claims for benefits;
(c) specifying, within the classes prescribed by the Lieutenant Governor in Council, the goods and services that are basic health services or extended health services for the purpose of the Plan.
RSA 1980 cA‑24 s7;1984 c26 s1;1992 c21 s1
Reassessment of claims
18(1) The Minister may, with respect to any claim for benefits that has been assessed under section 4(2), reassess the claim if the payment or rejection of the claim was made in error or as a result of erroneous or false information provided by the resident or practitioner concerned or by any other person acting on behalf of the resident or practitioner concerned.
(2) The Minister may, with respect to any claim for benefits, reassess the claim when, in the opinion of the Minister,
(a) the claim relates to a health service of a kind that the practitioner concerned has provided to the practitioner’s patients with a frequency that, in the circumstances, is unjustifiable,
(b) the total amount of benefits paid for the service was, in the circumstances, greater compensation to the practitioner for that service than it should have been,
(c) the service provided was, in the circumstances, inappropriate or unnecessary,
(d) the service provided could have been replaced by another professionally acceptable service for which a lower rate of benefits was payable, or
(e) in the case of a service provided by a physician, the service was not medically required.
(3) In reassessing claims pursuant to subsection (2), the Minister shall have regard to all the circumstances that, without limitation, shall include
(a) normal patterns of practice in Alberta of practitioners of the same profession who carry on similar types of practice in similar circumstances;
(b) accepted standards of practice in Alberta of the profession of the practitioner concerned;
(c) in cases referred to in subsection (2)(b), the amount that would have been reasonable compensation for the service provided, in view of the time and degree of skill involved in providing the service.
(4) When reassessing a claim under subsection (2), the Minister may
(a) establish a committee to prepare a report or make recommendations respecting the reassessment and may select and appoint persons from the roster established under subsection (4.1) as members of the committee, and
(b) have regard to any report or recommendations of the committee.
(4.1) The Minister may establish a roster of practitioners and members of the public who may be appointed to committees established under subsection (4).
(5) When the Minister reassesses claims pursuant to subsection (1) or (2), the Minister may make any appropriate adjustment in the amounts paid with respect to the claim and
(a) if the amounts paid were in excess of the benefits payable under the adjustment, recover the excess from the resident or the practitioner, as the case may be,
(i) by withholding from any benefits payable to the resident or the practitioner, as the case may be, an amount equivalent to the excess,
(ii) by civil action as though the excess were a debt owing to the Crown in right of Alberta, or
(iii) pursuant to an agreement between the Minister and the resident or practitioner concerned providing for the payment of the excess;
(b) if the amounts paid were less than the benefits payable under the adjustment, pay to the resident or the practitioner to whom the benefits were paid, as the case may be, the amount of the deficiency.
(6) The Minister may, with respect to any excess or deficiency referred to in subsection (5), charge or pay simple interest at a rate the Minister determines but not exceeding 8% per year.
(7) The Minister may withhold benefits payable to a practitioner or a resident until the completion of a reassessment under subsection (1) or (2) of claims relating to services provided by that practitioner.
(8) The Minister shall notify the resident or practitioner concerned by mail of any reassessment under this section and the person so notified may appeal the reassessment to the Court of Queen’s Bench by way of application if the application is returnable within 60 days after the date on which that person was notified.
RSA 2000 cA‑20 s18;RSA 2000 cH‑7 ss144,145,149; 2005 c13 s1;2007 c18 s1;2009 c53 s17
Order reducing future benefits
19(1) If a practitioner becomes liable under section 18(5) by reason of one or more reassessments of claims pursuant to subsection (2) of that section, the Minister may, with or without the consent of the practitioner, make an order directing that, after a date specified in the order and with respect to any specified kind of health service provided by that practitioner, the Minister will pay no benefits or only a portion of the benefits otherwise payable.
(2) An order under subsection (1)
(a) may be for a stated period or of indefinite duration;
(b) shall specify the health services to which it relates;
(c) shall specify, as to any service referred to in clause (b), whether no benefits are to be paid by the Minister in respect of it, or the portion of the benefits that are to be paid.
(3) A copy of an order under this section shall be served on the practitioner against whom it is made, and except in the case where it was made with the practitioner’s consent, the practitioner may, within 30 days after the date on which the practitioner received the copy of the order, apply to the Court of Queen’s Bench to have the order rescinded or varied.
(4) After the hearing of the application, the Court may direct the Minister
(a) to rescind the Minister’s order, if it considers the Minister had no reasonable justification for making it, or
(b) to vary the Minister’s order in the manner specified by the Court.
(5) When an order of the Minister under this section is of indefinite duration, the Minister shall review the order at least annually.
RSA 2000 cA‑20 s19;2009 c53 s17
Remuneration of practitioners
20 The Minister may enter into agreements or arrangements for the payment of benefits on a basis other than a fee for service basis.
RSA 1980 cA‑24 s11
Relationship between practitioner and patient
21(1) Nothing in this Act or the regulations
(a) interferes with the right of any person to the person’s own choice of practitioner,
(b) except sections 9 and 10, interferes with the right of any practitioner to make an agreement or arrangement with any person to collect from that person an amount in addition to the benefits payable by the Minister with respect to goods or services provided by the practitioner, if the agreement or arrangement is made before the goods or services are provided,
(c) except sections 9 and 10, affects the right of any resident to receive any health services or benefits in respect of them by reason of the resident’s choice of practitioner, or
(d) interferes with the right of a practitioner to accept or refuse to accept a patient who is a resident, subject to humanitarian considerations and the traditions and ethics of the profession of which the practitioner is a member.
(2) Nothing in this Act or the regulations is to be construed to prevent any resident who does not desire to claim or receive benefits for health services provided to the resident or resident’s dependants from assuming the responsibility for the payment of those costs.
RSA 1980 cA‑24 s12;1984 c26 s1;1986 c3 s5;1994 c2 s7
Disclosing health information
22(1) Except as permitted or required under this Act, the Minister or a person employed in the administration of this Act and authorized by the Minister may disclose health information acquired under this Act or the Health Insurance Premiums Act only in accordance with the Health Information Act.
(1.1) If there is an inconsistency or conflict between subsection (6.1) or (7) and the Health Information Act, subsection (6.1) or (7), as the case may be, prevails.
(2) The Minister or any person authorized by the Minister may, for the purpose of enforcing the Crown’s right of recovery under the Crown’s Right of Recovery Act, disclose information acquired under this Act.
(3) The Minister or a person employed in the administration of this Act and authorized by the Minister may disclose information pertaining to the date on which health services were provided, a description of those services, any diagnosis given by a person who provided the services, the name and address of the person who provided the services, the benefits paid for those services and the person to whom they were paid, the name and address of the person to whom the services were provided and any other information pertaining to the nature of the health services provided to any committee established to advise the Minister in respect of matters under section 18.
(4) The Minister or a person employed in the administration of this Act and authorized by the Minister may, in connection with the administration of the Criminal Code (Canada), disclose to the Minister of Justice and Solicitor General, or a person designated by the Minister of Justice and Solicitor General, information pertaining to the date on which health services were provided, a description of those services, any diagnosis given by a person who provided the services, the name and address of the person who provided the services, the benefits paid for those services and the person to whom they were paid, the name and address of the person to whom the services were provided and any other information coming to the knowledge of any person employed in the administration of this Act in the course of that person’s employment.
(5) The Minister or a person employed in the administration of this Act and authorized by the Minister may disclose information pertaining to the date on which health services were provided and a description of those services, the name and address of the person who provided the services, the benefits paid for those services and the person to whom they were paid, the name and address of the person to whom the services were provided and any other information pertaining to the nature of the health services provided, to The Workers’ Compensation Board, a director under the Child, Youth and Family Enhancement Act, the Sexually Transmitted Disease Control Unit of the Department of Health, or the Director of Medical Services appointed under the Occupational Health and Safety Act, if
(a) a member or officers of the Board, a director under the Child, Youth and Family Enhancement Act, or an officer of the Unit, or the Director of Medical Services, as the case may be, makes a written request for it, and
(b) the information required is necessary and relevant to a matter being dealt with by the Board, a director under the Child, Youth and Family Enhancement Act, an officer of the Unit or the Director of Medical Services.
(6) Notwithstanding subsection (5), the Minister or a person employed in the administration of this Act and authorized by the Minister may disclose to the Director of Medical Services for The Workers’ Compensation Board or the Director of Medical Services appointed under the Occupational Health and Safety Act any diagnosis given by a person who has provided health services to another person if
(a) the Director makes a written request for the diagnosis, and
(b) the health services provided relate to or likely relate to the occupation or former occupation of the person for whom the health services were provided or to a disease that is related to that person’s occupation or former occupation.
(6.1) The Minister or a person employed in the administration of this Act and authorized by the Minister may disclose individually identifying health information, other than a diagnosis given by a person who has provided health services, acquired under this Act
(a) to the individual who is the subject of the information,
(b) to a person referred to in section 104(1)(c) to (i) of the Health Information Act who is acting on behalf of the individual who is the subject of the information, or
(c) to a person other than the individual who is the subject of the information if the individual has consented to the disclosure in accordance with section 34 of the Health Information Act.
(7) The Minister or a person employed in the administration of this Act and authorized by the Minister may disclose information pertaining to the date on which health services were provided and a description of those services, the name and address of the person who provided the services, the registration number of the person who received the services, the benefits paid for those services and the person to whom they were paid, but the information may be disclosed only
(a) in connection with the administration of this Act, the regulations or the federal Act,
(b) in proceedings under this Act or the regulations,
(c) in connection with the administration of the Financial Administration Act or regulations, orders or directives under that Act,
(d) to the person who provided that service, the person’s solicitor or personal representative, the committee of the person’s estate, the person’s trustee in bankruptcy or other legal representative,
(e) - (g) repealed RSA 2000 cH‑5 s110,
(h) to a committee established under section 18(4) for purposes in connection with that section,
(i) to a medical examiner appointed under the Fatality Inquiries Act for the purposes of an investigation under that Act,
(j) to the Hospital Privileges Appeal Board established under the Hospitals Act for the purposes of an appeal to that Board, or
(k) to the Health Disciplines Board, a health discipline association or a Committee under the Health Disciplines Act, if the information is furnished in compliance with a notice under section 38(1) of the Health Disciplines Act, or
(l) to a hearings director of a college under the Health Professions Act, if the information is furnished in compliance with a notice under section 73 or 74 of the Health Professions Act.
(8) The Minister or a person employed in the administration of this Act and authorized by the Minister may disclose information, other than information related to health services, about a person, but the information may only be disclosed in connection with the administration of the Seniors Benefit Act.
(9) Notwithstanding subsection (7), the Minister or a person authorized by the Minister may disclose residents’ or practitioners’ registration information obtained under this Act or the Health Insurance Premiums Act
(a) for the purpose of the administration of this Act or the Health Insurance Premiums Act, the regulations under those Acts, the federal Act or any program that receives funds directly or indirectly from the Department of Health, or
(b) in proceedings under this Act, the Health Insurance Premiums Act or the regulations under those Acts.
(10) to (14) Repealed RSA 2000 cH‑5 s110.
(15) The Minister may enter into an agreement respecting the disclosure of practitioners’ registration information obtained under this Act or the Health Insurance Premiums Act with
(a) any Minister or government, or
(b) a person or entity designated in the regulations.
(16) The Minister may, in accordance with an agreement made under subsection (15), disclose practitioners’ registration information obtained under this Act or the Health Insurance Premiums Act.
(17) A government, person or entity that receives information under an agreement referred to in subsection (15) shall use the information only for the purposes specified in the agreement.
(18) With the consent of the Minister or an employee of the Government authorized by the Minister to do so, information of the kind referred to in subsection (5) and any other information pertaining to the nature of the health services provided and any diagnosis given by a person who provided the services may be disclosed or communicated to a disciplinary body of the organization of which that person is a member if an officer of that organization makes a written request for the information and states that the information is required for the purposes of investigating a complaint against one of its members or for use in disciplinary proceedings involving that member.
(19) The Minister may disclose to a disciplinary body of an organization any information referred to in subsection (7) and any other information pertaining to health services provided by a member of that organization if the Minister considers that it is in the interests of the public and of the organization that the information be so disclosed.
(20) In subsections (18) and (19), “disciplinary body” means
(a) the council or hearing tribunal of the College of Physicians and Surgeons of Alberta,
(b) the council or a hearing tribunal of the Alberta Dental Association and College,
(c) the council or a hearing tribunal of the Alberta College of Optometrists,
(d) the council or a hearing tribunal of the Alberta College and Association of Chiropractors under the Health Professions Act,
(e) the council or a hearing tribunal of the College of Podiatric Physicians of Alberta,
(f) the council or a hearing tribunal of the College of Alberta Denturists,
(g) the council or a hearing tribunal of the College of Opticians of Alberta,
(h) the council or a hearing tribunal of the College of Physical Therapists of Alberta, or
(i) the council or a hearing tribunal of the College and Association of Registered Nurses of Alberta.
(21) The Minister or a person authorized by the Minister may disclose information obtained under the Blue Cross agreement to the council or complaints director of the Alberta College of Pharmacists for that organization’s use in investigating a complaint against a member of that organization or in disciplinary hearings involving that member if
(a) an officer of the Alberta College of Pharmacists makes a written request for the information, or
(b) the Minister considers that it is in the interests of the public and of the Alberta College of Pharmacists that the information be disclosed.
(22) A person who contravenes this section is guilty of an offence.
(23) No report, form or return prescribed by or required for the purposes of this Act or the regulations shall be admitted in evidence in any judicial proceeding, other than a judicial proceeding under this Act, to adversely affect the interest of the person making the report, form or return.
(24) Notwithstanding subsection (23), the judge of the Provincial Court presiding at a public inquiry under the Fatality Inquiries Act may admit in evidence information obtained by a medical examiner under subsection (7)(i), but all proceedings related to that information shall be held in private.
(25) In this section,
(a) “health information” means health information as defined in the Health Information Act;
(b) “individually identifying”, when used to describe health information, means that the identity of the individual who is the subject of the information can be readily ascertained from the information.
RSA 2000 cA‑20 s22;RSA 2000 cH‑5 s110; RSA 2000 cH‑7 ss143,144,145,146,147,148,149,150,151,152,155; AR 49/2002 s3;2002 c30 s11;2003 c16 s117;2003 c39 s8; 2005 c13 ss1,4(4) and (5),(21);2007 c18 s1;2007 c32 s1(35),(41); 2008 cH‑4.3 s9;2008 c32 s6;2008 c34 s19;2009 cC‑35 s54; 2013 c10 s6
Protection from action
23 If a practitioner or an agent or employee of a practitioner discloses information to the Minister or to a person employed in the administration of this Act, no action lies against the practitioner or the agent or employee in respect of the disclosure of that information.
RSA 2000 cA‑20 s23;RSA 2000 cH‑5 s110
Assignment of benefits
24 Subject to the regulations, the right of any person to receive payment of benefits is not assignable and no sum owing by the Minister as benefits is liable to be charged or to be attached in any proceedings or subject to an order for equitable execution against the person entitled to receive payment of benefits.
RSA 1980 cA‑24 s15
Crown’s right of recovery
25 The Crown in right of Alberta is entitled to recover the Crown’s cost of health services under the Crown’s Right of Recovery Act.
RSA 2000 cA‑20 s25;2009 cC‑35 s54
Prohibitions
26(1) In this section,
(a) “carrier” means
(i) an insurer licensed under the Insurance Act, or
(ii) the Provincial Health Authorities of Alberta;
(b) “insurer” means
(i) a carrier, or
(ii) an employer, corporation or unincorporated group of persons that administers a self‑insurance plan;
(c) “self‑insurance plan” means a contract, plan or arrangement entered into, established, maintained in force or renewed under which coverage is provided
(i) by an employer for all or some of the employer’s employees who are residents of Alberta,
(ii) by a corporation for all or some of its members who are residents of Alberta, or
(iii) by an unincorporated group of persons for all or some of its members who are residents of Alberta.
(2) An insurer shall not enter into, issue, maintain in force or renew a contract or initiate or renew a self‑insurance plan under which any resident or group of residents is provided with any prepaid basic health services or extended health services or indemnification for all or part of the cost of any basic health services or extended health services.
(3) An insurer that contravenes subsection (2) is guilty of an offence.
(4) Notwithstanding subsection (2), an insurer may enter into, issue, maintain in force or renew a contract or initiate or renew a self‑insurance plan under which a resident is indemnified
(a) for the cost of any basic health service or extended health service provided outside Alberta that is over and above the benefits payable by the Minister for that service, or
(b) to the extent prescribed by the regulations and in those cases specified in the regulations, for the cost of any basic health services or extended health services other than insured services over and above the benefits payable by the Minister for those services.
(5) Subject to the regulations, if
(a) a carrier carries on a business of
(i) providing for the prepayment of the cost of health services other than basic health services by way of group contracts and individual contracts, or
(ii) selling insurance in respect of the cost of any health services other than basic health services by way of group contracts and individual contracts,
(b) the carrier has entered into such a group contract with an employer in respect of some or all of the employer’s employees who are residents of Alberta,
(c) an employee who is a resident of Alberta and is covered by that group contract retires from the employment of that employer in accordance with the employer’s retirement plan or policy, and
(d) that employee applies to the carrier, not later than 30 days after the date of the employee’s retirement, for an individual contract that is then being offered by the carrier to the public, and the employee pays the required initial premium or subscription,
the carrier shall issue the individual contract to that resident to provide coverage for that resident and any of that resident’s dependants included in the application, regardless of the age or state of health of the resident or any of the resident’s dependants.
(6) A carrier that contravenes subsection (5) is guilty of an offence.
(7) This section applies notwithstanding anything in the Insurance Act or any other Act.
RSA 1980 cA‑24 s17;1996 c6 s13
False statements
27(1) A person providing health services to a resident who wilfully makes a false statement in any report, form or return required to be submitted to the Minister to enable benefits to be paid to the resident or to any other person is guilty of an offence and liable to a fine of not less than $100 and not more than $1000.
(2) A person, other than a person providing health services to a resident, who wilfully makes a false statement in any report, form or return prescribed by or required for the purposes of this Act or the regulations is guilty of an offence and liable to a fine of not less than $100 and not more than $1000.
RSA 1980 cA‑24 s18
Information for claim
28(1) A person who provides health services but does not claim payment from the Minister of the benefits in respect of them shall provide to any other person authorized by the regulations to make the claim all information required for the purpose of making the claim and obtaining payment from the Minister.
(2) When a person provides information under subsection (1), the person shall do so in the form prescribed by the Minister.
(3) A person who contravenes this section is guilty of an offence.
RSA 1980 cA‑24 s19
Part 2 Optional Health Services
Definitions
29 In this Part,
(a) “optional contract” means a contract issued by the Minister to a resident pursuant to the regulations under this Part;
(b) “subscriber” means a person who is the holder of an optional contract;
(c) “subscription” means an amount payable to the Minister by a subscriber under an optional contract;
(d) “subsidy” means the amount prescribed in the regulations by which a subscription is reduced.
RSA 1980 cA‑24 s26
Regulations
30 The Lieutenant Governor in Council may make regulations
(a) authorizing the Minister to issue contracts to residents of Alberta providing insurance in respect of the cost of optional health services provided to the subscribers under it and their dependants;
(b) prescribing the classes of goods and services that are optional health services for the purposes of optional contracts;
(c) governing applications for optional contracts and the requirements to be met by applicants for those contracts;
(d) prescribing any terms or conditions of optional contracts;
(e) fixing subscription rates under optional contracts;
(f) authorizing the Minister to grant subsidies prescribing the amounts of the basis for calculating subsidies and prescribing the conditions as to eligibility of persons for subsidies;
(g) authorizing and empowering the Minister and a carrier as defined in section 26 to enter into an agreement providing for
(i) the allocation of optional contracts by the Minister to the carrier for the purposes of administration,
(ii) the fees to be paid to the carrier for its services,
(iii) the powers and duties of the carrier under the agreement in respect of the administration of the contracts, and
(iv) any other matters incidental to the allocation of the contracts or their administration;
(h) generally, providing for any other matter considered necessary for the purpose of administration and operation of this Part or to meet cases that may arise and for which no provision is made by this Act.
RSA 1980 cA‑24 s27
31 Repealed 2003 cI‑0.5 s52.
Regulations
32 The Minister may make regulations
(a) prescribing the rates of benefits payable for optional health services under optional contracts;
(b) specifying, within the classes prescribed by the Lieutenant Governor in Council, the goods and services that are optional health services for the purposes of optional contracts.
RSA 1980 cA‑24 s29
Part 3 General
Regulations
33 The Lieutenant Governor in Council may make regulations
(a) defining “dependant” for the purposes of the Plan, this Act and the regulations;
(b) providing for the establishment of committees in connection with the Plan and prescribing their powers and duties;
(c) prescribing the remuneration and expenses to be paid to committees appointed under clause (b);
(d) providing, as to any provision of the regulations, that its contravention is an offence;
(e) respecting and authorizing the types of recoverable payments that may be made under the Plan;
(f) respecting and authorizing the programs the costs of which may be paid under the Plan;
(g) generally, providing for any other matter considered necessary for the purpose of administration and operation of this Act or to meet cases that may arise and for which no provision is made by this Act.
RSA 1980 cA‑24 s30;1983 c32 s1;1984 c26 s1;1985 c32 s1; 1994 c31 s1
Retrospectivity of regulations
34 A regulation made under section 33(e) may be effective as of any date not earlier than November 1, 1981 and may validate recoverable payments referred to in the regulation that were made under the Plan since that effective date.
1983 c32 s1;1994 c31 s1
Retrospectivity of regulations
35 A regulation made under section 33(f) may be effective as of any date not earlier than January 1, 1985 and may validate the payment of the costs of the programs referred to in the regulation that were made under the Plan since that effective date.
1985 c32 s1;1994 c31 s1
Payments out of General Revenue Fund
36 The following may be paid out of the General Revenue Fund:
(a) recoverable payments pursuant to regulations under section 33(e);
(b) payments required to be made by the Minister pursuant to an arrangement made pursuant to section 88 of the Workers’ Compensation Act;
(c) any payment required to be made under the Plan pursuant to this or any other Act that is not paid under the authority of a supply vote.
RSA 1980 cA‑24 s31;1983 c32 s1;1985 c32 s1; 1987 c29 s2;1994 c31 s1
Benefits review committees
37(1) The Minister may establish one or more benefits review committees.
(2) The Minister may, with respect to a benefits review committee established under subsection (1),
(a) appoint or provide for the appointment of its members,
(b) prescribe the term of office of any members,
(c) designate a chair, vice‑chair and secretary, and
(d) authorize, fix and provide for the payment of remuneration and expenses to its members.
(3) A benefits review committee shall, when directed to do so by the Minister, conduct a review of the rates of benefits payable in respect of
(a) basic health services or any class of basic health services,
(b) extended health services or any class of extended health services, or
(c) optional health services or any class of optional health services,
whichever are specified in the direction.
(4) If a benefits review committee is directed to conduct a review under subsection (3), the Minister may direct the committee to conduct the review in consultation with representatives of an association of persons who provide the services concerned.
(5) After conducting a review, a benefits review committee shall make recommendations to the Minister with regard to the rates of benefits it has reviewed.
RSA 1980 cA‑24 s32
Forms
38 The Minister may prescribe any forms to be used under this Act or the regulations that the Minister considers necessary.
RSA 1980 cA‑24 s33
Examination of practitioner’s records
39(1) A person employed in the administration of this Act who is expressly authorized to do so by the Minister may, for the purpose of conducting an examination and audit of the claims for or payments of benefits relating to health services provided by a practitioner or group of practitioners,
(a) enter the premises of the practitioner or group of practitioners, and
(b) examine and audit any books, accounts, patient records or other records that are maintained by or on behalf of the practitioner or group of practitioners.
(2) A person conducting an examination and audit under subsection (1) may
(a) take extracts from or make copies of all or any part of the books, accounts and records referred to in subsection (1)(b), and
(b) make inquiries of the practitioner or the members of the group of practitioners respecting the claims, payments and health services.
(3) A practitioner and each member of a group of practitioners shall provide a person who has been authorized by the Minister under subsection (1) with access to the premises and to the books, accounts and records referred to in that subsection and shall answer the person’s inquiries respecting the claims, payments and health services.
(4) If a practitioner or a member of a group of practitioners fails or refuses to provide access to premises or to books, accounts or records or fails or refuses to answer inquiries as required by subsection (3), the Minister, after advising the council of the College or the board of directors or council of the organization that represents the practitioner’s profession of the failure or refusal, may withhold the payment of benefits to that practitioner in respect of claims made by that practitioner on behalf of residents until the access is provided or the answers are given.
RSA 2000 cA‑20 s39;2007 c18 s1
Disclosure of information to prevent or limit fraud or abuse of health services
39.1(1) In this section, “custodian” means a custodian as defined in the Health Information Act.
(2) A custodian may disclose information about a health service referred to in subsection (3) without the consent of the person who provided the health service or of the person who received the health service to a police service or the Minister of Justice and Solicitor General where the custodian reasonably believes
(a) that the information relates to the possible commission of an offence under a statute or regulation of Alberta or Canada by the person who provided the health service, and
(b) that the disclosure will detect or prevent fraud or limit abuse in the provision of health services.
(3) A custodian may disclose the following information under subsection (2):
(a) the name and business address of the person who provided the health service;
(b) the name and address of the person who received the health service;
(c) the date on which the health service was provided;
(d) the description of the health service provided;
(e) the benefits that were paid or charged in relation to the health service provided.
2009 c25 s27;2013 c10 s6
Special agreements
40(1) The Minister may enter into agreements with any government, person or unincorporated group of persons
(a) respecting any matter relating to the administration or operation of the Plan, or
(b) providing for any matter for which no provision is made elsewhere in this Act or in the regulations that the Minister considers necessary,
and the Minister may implement any agreement so made.
(2) An agreement under subsection (1) between the Minister and the Alberta Medical Association may provide for the submission of differences to arbitration.
(3) If an agreement between the Minister and the Alberta Medical Association provides for arbitration,
(a) the arbitration is final and binding on the Crown and the Alberta Medical Association, and
(b) the Arbitration Act does not apply to the arbitration.
RSA 1980 cA‑24 s35;1986 c3 s8
Blue Cross agreement
41(1) Subject to the approval of the Lieutenant Governor in Council, the Minister and the ABC Benefits Corporation may enter into an agreement, referred to as the Blue Cross agreement, providing for the following:
(a) programs to provide goods and services to residents and their dependants by the ABC Benefits Corporation on payment of the premiums prescribed in respect of the programs under the regulations made pursuant to the Health Insurance Premiums Act;
(b) the payments to be made by the Minister to the ABC Benefits Corporation with respect to goods and services provided to residents and their dependants under the Blue Cross agreement;
(c) the goods and services that are to be provided under the Blue Cross agreement with respect to residents and their dependants;
(d) generally, any matter in connection with or incidental to the matters referred to in clauses (a), (b) and (c).
(2) Only goods and services that are not basic health services or extended health services may be provided under the Blue Cross agreement.
(3) If a resident is in arrears of premiums under the Health Insurance Premiums Act, the resident and the resident’s dependants are not entitled to receive goods and services under the Blue Cross agreement.
(4) Subsection (3) does not apply if
(a) the resident or the resident’s spouse or adult interdependent partner is 65 years of age or over, or
(b) repealed 2003 cI‑0.5 s52.
(5) The Lieutenant Governor in Council may make regulations not inconsistent with the Blue Cross agreement governing any matter in connection with or incidental to matters provided for in the agreement.
RSA 2000 cA‑20 s41;2002 cA‑4.5 s16; 2003 cI‑0.5 s52;2004 c5 s3
General penalty
42 A person who is guilty of an offence under the regulations or under this Act and for which no penalty is specifically provided, is liable
(a) for a first offence, to a fine of not more than $500 and in default of payment to imprisonment for a term of not more than 30 days,
(b) for a 2nd offence, to a fine of not more than $1000 and in default of payment to imprisonment for a term of not more than 60 days, and
(c) for a 3rd or subsequent offence, to imprisonment for a term of not more than 6 months without the option of a fine.
RSA 1980 cA‑24 s38
Financial assistance
43(1) The Lieutenant Governor in Council may establish a program to provide financial assistance in cases where, because of the sickness or disability of a resident or dependant, the resident is faced with expenses that could not reasonably be foreseen and guarded against and that place an undue burden on the financial resources of the resident.
(2) The program may specify the types of expenses in respect of which assistance may be given and the portion of the expense that is to be borne by the resident.
RSA 1980 cA‑24 s39;1983 c81 s1;1984 c26 s1
Residence requirements
44(1) A resident who is entitled to benefits under this Act is also entitled to receive, without charge, insured services that are provided under
(a) repealed 2008 cH‑4.3 s9;
(b) the Mental Health Act;
(c) the Public Health Act;
(d) any other Act under which insured services are provided,
notwithstanding any provision of those Acts or the regulations under them that provide requirements as to residence in Alberta that are inconsistent with or more onerous than the requirements as to residence under the Plan.
(2) Subsection (1) does not affect any provision in any Act referred to in that subsection or in any regulations under such an Act that pertain to requirements as to residence in Alberta in relation to the provision of any services that are not insured services.
RSA 2000 cA‑20 s44; 2008 cH‑4.3 s9
