5 Benefits for
services outside Canada
6 Included in
amount of benefits
7 Conditional
benefits
8 Alteration of
appearance surgery
9 Specialist
benefits
10 Rates set by
regional health authority
11 Repeal
12 Expiry
Definitions
1 In this Regulation,
(a) “Act”
means the Alberta Health Care Insurance Act;
(b) “insured
medical services” means
(i) all services provided by physicians that are medically required,
and
(ii) any other services that are declared to be insured services
pursuant to section 2 of the Act,
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;
(c) “Schedule
of Medical Benefits” means the Schedule of Medical Benefits prepared and
published by the Department of Health and Wellness and approved by the
Minister.
Eligibility
2(1) Benefits
are payable in accordance with the regulations under the Act for insured
medical services provided to a resident of Alberta.
(2) Notwithstanding
subsection (1), benefits are not payable for insured medical 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.
Benefits for services
in Alberta
3(1) The
benefits payable for insured medical services provided to a resident of Alberta
in Alberta and the descriptions of those services are set out in the Schedule
of Medical Benefits.
(2) Notwithstanding
subsection (1), unless otherwise approved by the Minister, the benefits payable
for insured medical services provided to a resident of Alberta in Alberta are
limited to the lesser of
(a) the
amount claimed, and
(b) the
rates established in the Schedule of Medical Benefits.
Benefits for services
in Canada
4(1) In
this section, “medical reciprocal agreement” means an agreement referred to in
section 17 of the Alberta Health Care Insurance Regulation.
(2) Notwithstanding
any provision in this Regulation, benefits for insured medical services
provided to a resident of Alberta by a physician in another province or
territory of Canada that are claimed under a medical reciprocal agreement are
payable
(a) according
to the rules established for payment of benefits in that province or territory,
and
(b) at
the rates established by that province or territory.
(3) Notwithstanding
any provision in this Regulation, benefits for insured medical services
provided to a resident of Alberta by a physician in another province or territory
of Canada that are not claimed under a medical reciprocal agreement are
determined as follows:
(a) if the insured
medical services are insured services under the legislation of that province or
territory, the benefits are payable according to the rules established for
payment of benefits in that province or territory and are limited to the lesser
of
(i) the amount claimed, and
(ii) the rates established by that province or territory;
(b) if the insured
medical services are not insured services under the legislation of that
province or territory, the benefits are payable according to the Act and the
regulations under the Act, and are limited to the lesser of
(i) the amount claimed, and
(ii) the rates established in the Schedule of Medical Benefits.
(4) No benefit is payable for services provided to a resident
of Alberta by a physician in another province or territory of Canada unless the
services are insured medical services in Alberta or are claimed under a medical
reciprocal agreement.
Benefits for services
outside Canada
5(1) Subject to the Out‑of ‑Country
Health Services Regulation, the benefits payable for insured medical
services provided to a resident of Alberta by a physician outside Canada are
limited to the lesser of
(a) the
amount claimed, and
(b) the
rates established by the Minister.
(2) No
benefits are payable for services provided to a resident of Alberta by a
physician outside Canada if the services are not insured medical services in
Alberta.
Included in amount of
benefits
6 The benefits payable for insured medical
services provided to a resident of Alberta by a physician include an amount for
the following:
(a) performing
the insured medical service;
(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.
Conditional benefits
7 Benefits are not payable for pathology
services or diagnostic imaging services provided to a resident of Alberta in
Alberta unless the physician that provides the insured medical service has been
accredited to provide the insured medical service by the College of Physicians
and Surgeons of Alberta.
Alteration of
appearance surgery
8 No benefit is payable with respect to a
surgical procedure for the alteration of appearance performed for emotional,
psychological or psychiatric reasons unless the Minister gives approval prior
to the surgery being performed.
Specialist benefits
9(1) Specialist
benefits for insured medical services provided in Alberta are payable only to a
physician who has received
(a) a
specialist certificate in accordance with the Medical Profession Act, or
(b) an
interim certificate issued by the College of Physicians and Surgeons of Alberta
indicating that the physician has completed the requirements for a specialist
certificate and is awaiting formal recognition.
(2) Specialist
benefits for insured medical services provided to a resident of Alberta in a
place outside of Alberta are payable only if the physician who provided the
insured medical services is accredited as a specialist in that place.
Rates set by regional
health authority
10(1) The benefits payable for laboratory medicine
services and pathology services provided to a resident of Alberta in Alberta
are the rates determined by the regional health authority of the health region
in which the services are provided.
(2) The
benefits referred to in subsection (1) are not payable unless the service is
provided by a person authorized by a regional health authority to provide the
service.
Repeal
11 The Medical Benefits Regulation
(AR 173/93) is repealed.
Expiry
12 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.
