Extended Health Services Benefits Regulation

Link to law: http://www.qp.alberta.ca/1266.cfm?page=2006_083.cfm&leg_type=Regs&isbncln=9780779767106&display=html
Published: 2012

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AR 83/2006 EXTENDED HEALTH SERVICES BENEFITS REGULATION (Consolidated up to 170/2012)
ALBERTA REGULATION 83/2006
Alberta Health Care Insurance Act
EXTENDED HEALTH SERVICES BENEFITS REGULATION
Table of Contents
                1       Definitions
                2       Eligibility
                3       Dental benefits payable                 4       Optical benefits payable
                5       Included in amount of benefits
                6       Benefit limits ‑ dental
                7       Benefit limits ‑ optical
                8       Repeal
                9       Expiry
List of Dentist Goods and Services List of Denturist Goods and Services List of Optician Goods and Services List of Optometrist Goods and Services
Definitions
1   In this Regulation,
                                 (a)    “Act” means the Alberta Health Care Insurance Act;
                                 (b)    “dental extended health services” means the goods and services set out in the List of Dentist Goods and Services and the List of Denturist Goods and Services in this Regulation;
                                 (c)    “dependant” means a dependant as defined in the Alberta Health Care Insurance Regulation;
                                 (d)    “eligible resident” means
                                           (i)    a resident who is receiving a widow’s pension under the Widows’ Pension Act, and
                                          (ii)    a person who is a dependant of a person referred to in subclause (i);
                                 (e)    “optical extended health services” means the goods and services set out in the List of Optician Goods and Services and the List of Optometrist Goods and Services in this Regulation;
                                 (f)    “Schedule of Dental Extended Health Benefits” means the Schedule of Dental Extended Health Benefits prepared and published by the Department of Health and approved by the Minister;
                                 (g)    “Schedule of Optical Extended Health Benefits” means the Schedule of Optical Extended Health Benefits prepared and published by the Department of Health and approved by the Minister.
AR 83/2006 s1;170/2012
Eligibility
2(1)  Benefits are payable to or on behalf of eligible residents for the following extended health services provided to an eligible resident:
                                 (a)    goods and services in the List of Dentist Goods and Services in this Regulation that are provided by or under the supervision of a dentist;
                                 (b)    goods and services in the List of Denturist Goods and Services in this Regulation that are provided by or under the supervision of a denturist;
                                 (c)    goods and services in the List of Optician Goods and Services in this Regulation that are provided by or under the supervision of an optician;
                                 (d)    goods and services in the List of Optometrist Goods and Services in this Regulation that are provided by or under the supervision of an optometrist.
(2)  Notwithstanding subsection (1), benefits are not payable for extended health services if a declaration under section 25 of the Health Insurance Premiums Act is in effect in respect of the person who receives the services.
Dental benefits payable
3(1)  The benefits payable for dental extended health services and the descriptions of those services are set out in the Schedule of Dental Extended Health Benefits.
(2)  Notwithstanding subsection (1), the benefits payable for dental extended health services provided to an eligible resident by a practitioner are limited to the lesser of
                                 (a)    the amount claimed, and
                                 (b)    the rates established in the Schedule of Dental Extended Health Benefits.
Optical benefits payable
4(1)  The benefits payable for optical extended health services and the descriptions of those services are set out in the Schedule of Optical Extended Health Benefits.
(2)  Notwithstanding subsection (1), the benefits payable for optical extended health services provided to an eligible resident by a practitioner are limited to the lesser of
                                 (a)    the amount claimed, and
                                 (b)    the rates established in the Schedule of Optical Extended Health Benefits.
Included in amount of benefits
5   The benefits payable for dental extended health services or optical extended health services provided to an eligible resident by a practitioner include an amount for the following:
                                 (a)    performing the dental extended health services or optical extended health services;
                                 (b)    administration;
                                 (c)    recording of information regarding the services provided unless the recording of the information is for the purposes of a third party;
                                 (d)    completing and submitting claims;
                                 (e)    discussion or correspondence with a referring health care professional regarding treatment or a service to be provided to a patient directly related to managing the patient’s care, unless otherwise provided in this Regulation or the Alberta Health Care Insurance Regulation.
Benefit limits ‑ dental
6   Benefits payable for dental extended health services provided to an eligible resident are subject to the following limitations:
                                 (a)    a benefit for a complete denture for a given arch (upper or lower jaw) will be paid no more frequently than once every 5 years, and then only if no previous benefit has been paid for a denture or reset (including rebase) for the arch during that period;
                                 (b)    a benefit for a partial denture for a given arch will be paid no more frequently than once every 5 years;
                                 (c)    a benefit for a reline for a denture will be paid no more frequently than once every 2 years, and then only if no previous benefit has been paid for a reline or rebase for the denture during that period.
Benefit limits ‑ optical
7(1)  The benefits payable for optical extended health services are limited to one good or service in each 3‑year period beginning January 1, 1995.
(2)  Notwithstanding subsection (1), benefits may be paid for 2 pairs of glasses, 2 pairs of lenses or 2 lenses with different corrections, instead of bifocals, but the glasses or lenses must be purchased at the same time and the benefit to be paid must not exceed the benefit payable for bifocals.
Repeal
8   The Extended Health Services Benefits Regulation (AR 383/94) is repealed.
Expiry
9   For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on February 15, 2016. List of Dentist Goods and Services   
                                 (a)    examinations;
                                 (b)    radiographs;
                                 (c)    restorative services;
                                 (d)    endodontics;
                                 (e)    periodontics;
                                 (f)    dentures;
                                 (g)    repairs/additions;
                                 (h)    relines;
                                  (i)    tissue conditioning;
                                  (j)    oral and maxillofacial surgery.
List of Denturist Goods and Services
                                 (a)    dentures;
                                 (b)    relines;
                                 (c)    repairs/additions;
                                 (d)    tissue conditioning;
                                 (e)    oral exams.
List of Optician Goods and Services
                                 (a)    single vision lens for distance;
                                 (b)    single vision lens for reading;
                                 (c)    bifocal lens;
                                 (d)    multifocal lens;
                                 (e)    complete pair of glasses.
List of Optometrist Goods and Services
                                 (a)    single vision lens for distance;
                                 (b)    single vision lens for reading;
                                 (c)    bifocal lens;
                                 (d)    multifocal lens;
                                 (e)    complete pair of glasses.