14 Extra billing
15 Information to
be provided by practitioners
16 Minister to
notify Alberta Cancer Board
Part 4
Reciprocal Payments
17 Minister re
reciprocal payments
Part 5
Program Costs
18 Program and
program benefits
Part 6
General
19 Health
Insurance Supplementary Fund (Canada)
20 Contract or
self‑insurance plan allowed under section 26 of Act
21 Repeal
22 Expiry
Definitions
1(1) In
this Regulation,
(a) “accredited
educational institute” means a high school, college, university or any other
educational institution recognized as such by the Minister for the purposes of
this Regulation;
(b) “Act”
means the Alberta Health Care Insurance Act;
(c) “child”
includes a foster child and any other person in respect of whom a resident or
other person stands in the place of a parent.
(2) In
the Act and the regulations, “dependant” means, in relation to any person,
(a) the
spouse or adult interdependent partner of that person,
(b) each
unmarried child under the age of 21 years who is wholly dependent on that
person for support,
(c) each
unmarried child less than 25 years of age who is in full‑time attendance
at an accredited educational institute, and
(d) each
unmarried child 21 years of age or more who is wholly dependent on that person
by reason of mental or physical infirmity.
Part 1
Interpretation
Insured oral and
maxillofacial surgery services
2 Those
services that are provided by a dentist in the field of oral and maxillofacial
surgery for which benefits are payable under the Oral and Maxillofacial
Surgery Benefits Regulation are hereby specified as insured services for
the purposes of section 1(n)(ii) of the Act.
Insured podiatric
surgery services
2.1 The services referred to in
section 1(b)(v) of the Act for which benefits are payable under the Podiatric
Surgery Benefits Regulation are hereby declared to be insured services for
the purposes of the Plan.
AR 128/2006 s2
Temporarily absent
from Alberta
3(1) For
the purposes of this Regulation and section 5(2) of the Act, a person is
“temporarily absent from Alberta” if the person
(a) stays
in another province or territory for a period that will not exceed 12
consecutive months, or
(b) stays
outside Canada for a period that will not exceed 6 consecutive months,
and the person intends
to return to and maintain permanent residence in Alberta on the conclusion of
the stay outside Alberta.
(2) The
Minister may extend any period referred to in subsection (1) for a further
period of time that the Minister considers proper,
(a) if
the person provides evidence satisfactory to the Minister that the person
intends to return to and maintain permanent residence in Alberta after the
extended period of time, or
(b) if,
in the opinion of the Minister, there are unforeseen and extenuating
circumstances.
Information under
section 22 of the Act
4 For the purposes of section 22 of the
Act, “residents’ registration information” includes
(a) any
information necessary to identify or contact a personal representative,
guardian, trustee or other legal representative of a resident, and
(b) in
the case of a person who is deemed to be a resident under section 6, any
information that the Minister requires or receives regarding the person that
would constitute residents’ registration information if required or received
from any resident.
Deemed residents from
outside Canada
5(1) Subject to subsection (2), the following
persons whose ordinary place of residence is outside Canada are deemed to be
residents of Alberta for the purposes of the Act:
(a) a
person who is in Alberta under a work assignment, contract or arrangement and
applies for registration under the Plan;
(b) a
person who is in full‑time attendance as a student at an accredited
educational institute in Alberta;
(c) a
person who is registered under the Health Insurance Premiums Act as a
dependant of the person referred to in clause (a) or (b).
(2) Subsection
(1) applies only if a person referred to in subsection (1)(a), (b) or (c)
(a) has
been lawfully admitted to Canada,
(b) has
established residence in Alberta, and
(c) intends
to remain in Alberta for 12 or more consecutive months.
Resident under
section 22 of the Act
6 A person whose ordinary place of
residence is outside Alberta is deemed to be a resident of Alberta for the
purposes of section 22 of the Act if that person receives health services in
Alberta pursuant to any policy, program or arrangement for which the Department
of Health and Wellness
(a) makes
payment directly or indirectly, or
(b) provides
or arranges any funding or administrative services.
Dependants deemed
residents
7(1) When a child is born outside Alberta to parents
who are both temporarily absent from Alberta and are both registered under the Health
Insurance Premiums Act, the child is deemed to be a resident of Alberta for
the purposes of the Act.
(2) If
a dependant of a resident is
(a) within
Canada on a vacation or visit of not more than 12 months’ duration, or
(b) in
full‑time attendance as a student at an accredited educational institute,
with the intention to
become a permanent resident of Alberta on the conclusion of the vacation, visit
or attendance as a student at an accredited educational institute, that
dependant is deemed to be a resident of Alberta for the purposes of the Act.
Resident who
establishes permanent residence elsewhere
8(1) A resident who leaves Alberta for the purpose
of establishing permanent residence in another province or territory of Canada
is entitled to continue the resident’s coverage under the Plan for the period
beginning on the day the resident ceases to be a resident of Alberta and ending
on the last day of the 2nd month following the month of arrival in the new
province or territory, unless extended under subsection (3).
(2) Notwithstanding
subsection (1), if a resident leaves Alberta for the purpose of establishing
permanent residence outside Alberta and the spouse or adult interdependent
partner of the resident
(a) maintains
a home in Alberta,
(b) is
not living apart from the resident pursuant to a court order or separation
agreement or otherwise, and
(c) intends
to join the resident,
the resident is
entitled to continue coverage under the Plan for a period not exceeding 12
months beginning on the day the resident ceases to be resident in Alberta.
(3) If
the resident informs the Minister that vacation or travelling time will be
taken in conjunction with the move referred to in subsection (1), the Minister
may extend the duration of the coverage under the Plan for a further period not
exceeding one month, except that under no circumstances may the total duration
of the coverage under the Plan extend beyond the last day of the 4th month
following the month of leaving Alberta, unless extended under subsection (4).
(4) If
a resident, while travelling between Alberta and the province or territory of
Canada in which the resident intends to establish permanent residence, is
hospitalized, the resident remains entitled to continuing coverage under the
Plan while the resident is continuously hospitalized for up to 12 months from
the date the resident first became hospitalized.
(5) Subject
to subsection (7), if a resident is establishing permanent residence outside
Canada and notifies the Minister that the resident wishes to continue to be
covered under the Plan, that resident is entitled to be covered under the Plan
for the period beginning the day that resident ceases to be a resident of
Alberta and ending one, 2 or 3 months, as prescribed by the Minister, following
the month the resident ceases to be a resident of Alberta, unless the period is
extended under subsection (6).
(6) Subject
to subsection (7), if a person requires continuing coverage under the Plan
while en route from Alberta to establish permanent residence outside Canada,
the Minister may, in a particular case in which the Minister finds that
unforeseen and extenuating circumstances so warrant, extend the duration of the
continuing coverage under the Plan for a further period not exceeding 12
months.
(7) A
resident is not entitled to continuing coverage under the Plan until the
resident has paid
(a) all
arrears of premiums, and
(b) the
premiums applicable to the period of the continuing coverage
pursuant to the Health
Insurance Premiums Regulation (AR 217/81).
Part 2
Health Services and Benefits
Benefits payable re
basic health services
9 The benefits payable by the Minister in
respect of basic health services are the benefits specified in the regulations
under section 17 of the Act.
Benefits payable re
extended health services
10 The benefits payable in respect of
extended health services pursuant to section 3(2) of the Act are
(a) for
those goods and services provided by a dentist, a denturist, an optometrist or
an optician that are listed in the Extended Health Services Benefits
Regulation, and
(b) subject
to any terms and conditions that may form part of an agreement made under
section 20 or 40 of the Act.
When entitlement
commences
11(1) Entitlement to benefits for extended health
services pursuant to section 3(2)(b) of the Act shall commence
(a) on
the date on which the registration under the Health Insurance Premiums Act
becomes effective, if the resident is receiving a widow’s pension at that time,
or
(b) on
the date the resident becomes eligible for a widow’s pension, if that date occurs
after the effective date of registration.
(2) Entitlement
to benefits for extended health services pursuant to section 3(2)(b) of the Act
shall cease
(a) at
the end of the 2nd month following the month in which the death of the resident
who was receiving the widow’s pension occurs, or
(b) at
the end of the 2nd month following the month in which the resident becomes
ineligible for the widow’s pension,
whichever occurs
first.
Services not
considered basic or extended health services
12(1) For
the purposes of this section, a service is available in Canada if a resident
could have obtained the service in Canada within the time period generally
accepted as reasonable by the medical or dental profession for any resident
with a similar condition.
(2) Unless
otherwise approved by the Minister, the following services are not basic health
services or extended health services:
(a) medical‑legal
services, including
(i) examinations performed at the request of third parties in
connection with legal proceedings,
(ii) giving of evidence by a practitioner in legal proceedings, or
(iii) preparation of reports or other documents relating to the results
of a practitioner’s examination for use in legal proceedings or otherwise and
whether requested by the patient or by a third party;
(b) advice
by telephone or any other means of telecommunication and toll charges or other
charges for telephone calls or telecommunication services except as provided
for in the Schedule of Medical Benefits under the Medical Benefits Regulation;
(c) transportation
services, including ambulance services for
(i) transportation of a patient to a hospital or to a practitioner
elsewhere, or
(ii) transportation of a practitioner to a hospital or to a patient
elsewhere,
whether the costs of those
services are by way of charges for distance or charges for travelling time;
(d) examinations
required for the use of third parties;
(e) services
that a resident is eligible to receive under a statute of any other province or
territory, the Health Care Protection Act, the Hospitals Act, any
statute relating to workers’ compensation or under any statute of the
Parliament of Canada, including
(i) the Aeronautics Act (Canada),
(ii) the Civilian War‑related Benefits Act (Canada),
(iii) the Corrections and Conditional Release Act (Canada),
(iv) the Government Employees Compensation Act (Canada),
(v) the Merchant Seamen Compensation Act (Canada),
(vi) the National Defence Act (Canada),
(vii) the Pension Act (Canada), and
(viii) the Royal Canadian Mounted Police Act (Canada);
(f) services
not provided by or under the supervision of a practitioner, except as provided
for in the Schedule of Medical Benefits under the Medical Benefits
Regulation;
(g) services
for which a patient would not be liable to pay in the absence of benefits for
health services;
(h) services
that the Minister, on review of the evidence, determines not to be health
services because the services
(i) are not required, or
(ii) are experimental or applied research;
(i) services
in connection with group immunizations against a disease or services in
connection with group examinations by a practitioner;
(j) services
provided by a practitioner to the practitioner’s children, grandchildren,
siblings, parents, grandparents, spouse or adult interdependent partner or any
person who is dependent on the practitioner for support;
(k) laboratory
and diagnostic imaging services provided in Alberta in a facility that does not
meet the criteria for registration under the Alberta Health Care Insurance Plan
and that is not registered with the Alberta Health Care Insurance Plan or for
which benefits are not payable under the Medical Benefits Regulation,
the Podiatric Surgery Benefits Regulation, the Podiatric Benefits
Regulation, the Oral and Maxillofacial Surgery Benefits Regulation
or the Chiropractic Benefits Regulation;
(l) services
provided outside Canada that are available inside Canada (other than services
provided in the case of an emergency);
(m) services
provided outside Canada that are not available inside Canada unless approved by
the Out‑of‑Country Health Services Committee or the Out‑of‑Country
Health Services Appeal Panel under the Out‑of‑Country Health
Services Regulation;
(n) drugs,
casts, surgical appliances and special bandages, except as provided for in the
Schedule of Medical Benefits under the Medical Benefits Regulation, the
Schedule of Podiatric Surgery Benefits under the Podiatric Surgery Benefits
Regulation or the Schedule of Podiatric Benefits under the Podiatric
Benefits Regulation;
(o) non‑hospital
facility fee charges associated with any health services provided in a non‑hospital
facility outside of Alberta;
(p) services for substance abuse, eating
disorders or other addictive disorders provided outside of Alberta.
AR 76/2006 s12;128/2006
Diagnostic imaging
services
13(1) If benefits are paid or payable with respect to
diagnostic imaging services provided to a resident, the practitioner who
provided the services shall, as soon as is reasonably practicable after a request
is made by the resident, make the resulting diagnostic images available to any
other practitioner designated by the resident.
(2) A
practitioner who receives diagnostic images under subsection (1)
(a) may
make copies of the images, and
(b) shall,
as soon as is reasonably practicable after the images have served the purpose
for which they were required, return the original images to the practitioner
who made the images available.
(3) If
a practitioner fails to comply with a request under subsection (1),
(a) the
Minister may withhold the benefits payable to the practitioner with respect to
the diagnostic imaging services provided to the resident, or
(b) if
benefits have already been paid to the practitioner or resident with respect to
those services, the practitioner is liable for and shall repay to the Minister
the benefits paid in respect of the services.
(4) If
the practitioner fails to repay benefits under subsection (3)(b), the Minister
may withhold the amount of the benefits from any other benefits payable to the
practitioner.
(5) If
a practitioner fails to comply with subsection (2)(b), the Minister may
withhold from benefits payable to the practitioner an amount equivalent to the
benefits paid or payable with respect to the diagnostic imaging services
provided by the practitioner who made the diagnostic images available.
(6) If
benefits are withheld by the Minister under subsection (3)(a), (4) or (5) or a
practitioner repays benefits to the Minister under subsection (3)(b), the
practitioner is not entitled to collect any amount from any person in respect
of the services involved.
Part 3
Claims
Extra billing
14(1) Except as provided for in section 21 of the
Act, a practitioner must not submit an account for payment to a resident or to
another Government department or agency if the practitioner has submitted or
intends to submit a claim for benefits to the Minister.
(2) A person who contravenes subsection
(1) is guilty of an offence.
(3) To
avoid any doubt, for the purposes of the Act and regulations, any good or
service provided by a practitioner that is listed in the Schedule of Medical
Benefits under the Medical Benefits Regulation, the Schedule of
Podiatric Surgery Benefits under the Podiatric Surgery Benefits Regulation
or the Schedule of Oral and Maxillofacial Surgery Benefits under the Oral
and Maxillofacial Surgery Benefits Regulation is an insured service,
whether the cost of that good or service is greater than or less than the
maximum benefit payable for the good or service provided.
AR 76/2006 s14;128/2006
Information to be
provided by practitioners
15(1) A
practitioner must, in a form approved by the Minister, provide to the Minister
any information that the Minister may require regarding the practitioner’s
training, the type of practice the practitioner is engaged in or any other
related information.
(2) If
a practitioner provides goods or services to a resident of Alberta, the
practitioner must retain the original documentation relating to the goods or
services provided for a period of not less than 6 years and must, on request,
make the documentation available to the Minister.
(3) If a practitioner on behalf of a
resident claims benefits in respect of diagnosis or treatment of cancer, the
practitioner, from time to time, must report to the Alberta Cancer Board, in
writing, on forms established by that Board, any information that the Board
requires concerning the claim, including the name of the person in respect of
whom the services were provided, the nature of the illness and particulars of
the services.
Minister to notify
Alberta Cancer Board
16(1) If requested to do so by the Alberta Cancer
Board for any specific resident, the Minister shall notify the Alberta Cancer
Board whenever a claim for benefits is paid in respect of any services provided
to that resident that may relate to cancer.
(2) If
benefits for services are paid by the Minister before the practitioner complies
with section 15(3) in respect of the reports, the College of Physicians and
Surgeons of Alberta or the Alberta Dental Association and College, as the case
may be, may, on being notified to do so by the Alberta Cancer Board, request,
in writing, the practitioner to submit the reports to the Alberta Cancer Board.
(3) If
a practitioner, on being requested by the College of Physicians and Surgeons of
Alberta or the Alberta Dental Association and College under subsection (2) to
submit the reports under section 15(3) fails to do so, the practitioner is
liable for and shall repay to the Minister the benefits paid to the
practitioner in respect of the services and the amount of such benefits
constitutes a debt payable to the Crown.
(4) If
the practitioner fails to repay benefits under subsection (3), the Minister may
withhold the amount of the benefits from any other benefits payable to the
practitioner.
(5) If
a practitioner repays benefits to the Minister under subsection (3) or the
benefits are withheld by the Minister under subsection (4), the practitioner is
not entitled to collect any amount from any person in respect of the services
involved.
(6) Subsections
(3), (4) and (5) cease to apply when the practitioner complies with section
15(3) in respect of the reports.
Part 4
Reciprocal Payments
Minister re reciprocal
payments
17 The Minister is authorized under the Plan
to make payments to a hospital or a physician in Alberta in respect of insured
services provided by the hospital or by the physician to residents of another
province or territory of Canada, where the making of such payments is the
subject of an agreement between Her Majesty the Queen in right of the Province
of Alberta as represented by the Minister of Health and Wellness and the
government of the other province or territory as represented by the appropriate
Minister of that province or territory, and the agreement provides that those
payments are recoverable from the provincial or territorial health authority of
the other province or territory.
Part 5
Program Costs
Program and program
benefits
18(1) In this section,
(a) “program”
means a program established under subsection (2);
(b) “program
benefit” means the benefit referred to in subsection (2).
(2) The
Minister is authorized to establish by order or enter into an agreement with a
person for the establishment of a program to benefit one or more physicians or
categories of physicians who are entitled to receive payment of benefits under
the Plan.
(3) The
order or agreement establishing a program must
(a) provide
for the basis on which eligibility for program benefits is determined,
(b) provide
for the basis on which the rates for program benefits are determined,
(c) prescribe
the manner in which program benefits are to be paid and the persons to whom
program benefits are to be paid, the conditions of payment, if any, and the
information required to be submitted in connection with claims for program
benefits,
(d) provide
for the term or manner of termination of the program,
(e) provide
for the payment of costs, if any, to administer the program and the person to
whom the costs are to be paid, and
(f) include
such other provisions as the Minister considers appropriate in respect of the
program.
(4) The
Minister is authorized to pay the administration costs and program benefits of
a program under the Plan.
Part 6
General
Health Insurance
Supplementary Fund (Canada)
19 The Minister may participate in the
Health Insurance Supplementary Fund (Canada) in respect of persons of Alberta
who through no fault of their own have ceased to be entitled to benefits or are
not eligible for benefits.
Contract or
self-insurance plan allowed under section 26 of Act
20(1) Pursuant to section 26 of the Act, an insurer shall not
enter into or issue a contract or initiate a self‑insurance plan covering
indemnification for the cost of basic health services or extended health
services provided within Alberta except as otherwise provided in this section.
(2) An
insurer may enter into or issue a contract or initiate a self‑insurance
plan under which a resident is indemnified for
(a) the
cost of chiropractic services provided to the resident by a chiropractor in
excess of the amount that is payable in respect of each service under the Chiropractic
Benefits Regulation,
(b) the
cost of podiatric services provided to the resident by a podiatrist in excess
of the amount that is payable in respect of each service under the Podiatric
Benefits Regulation,
(c) the
cost of optometric services provided to the resident by an optometrist in
excess of the amount that is payable under the Optometric Benefits
Regulation, or
(d) the
cost of extended health services provided to the resident where those services
are outside the limits prescribed in the Extended Health Services Benefits
Regulation.
(3) Notwithstanding
subsection (2)(a), an insurer may enter into or issue a contract or initiate a
self‑insurance plan under which a resident is indemnified for the cost of
chiropractic services provided to the person pursuant to the Diagnostic and
Treatment Protocols Regulation (AR 122/2004).
(4) Notwithstanding subsection (2),
nothing in this Regulation prevents an individual from receiving indemnity for
the cost of extended health services where the individual was eligible to
receive such indemnity through some other plan provided by a private insurance
carrier before the individual or the individual’s dependants became eligible
for extended benefits.
Repeal
21 The Alberta Health Care Insurance
Regulation (AR 216/81) is repealed.
Expiry
22 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.