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AR 202/2007 OPTOMETRIC BENEFITS REGULATION

(Consolidated up to 186/2014)

ALBERTA REGULATION 202/2007

Alberta Health Care Insurance Act

OPTOMETRIC BENEFITS REGULATION

Table of Contents

Part 1
General Provisions

                1      Definitions

                2      Eligibility

                3      Benefits set in Schedule of Optometric Benefits


                4      Benefits to include amounts for specific services

                5      Benefits not payable

Part 2
Eligible Residents who are
Seniors and Children

                6      Definition

                7      Optometric services

                8      Benefit limits

                9      Benefits for low vision aid tests

Part 3
Eligible Residents of All Ages

              10      Definitions

              11      Optometric services

              12      Benefit limits

              13      Benefit for CAVF test

           13.1      Benefits for internal retinal photography and retinal imaging

              14      Co‑management arrangement

              15      Billing rules for Part 3

              16      Services for which no benefits payable

Part 4
Repeal, Expiry and
Coming into Force

              17      Repeal

              18      Expiry

              19      Coming into force

Part 1
General Provisions

Definitions

1   In this Regulation,

                               (a)    “Act” means the Alberta Health Care Insurance Act;

                           (a.1)    “benefit period” means a period of 12 consecutive months commencing on July 1 in each year;

                              (b)    “computer assisted visual fields test” or “CAVF test” means an assessment of the eye and vision system of an individual for the purpose of mapping the individual’s visual fields;

                               (c)    “optometric services” means

                                        (i)    for eligible residents described in Part 2, the services specified in section 7, and

                                      (ii)    for eligible residents described in Part 3, the services specified in section 11;

                              (d)    “Schedule of Optometric Benefits” means the Schedule of Optometric Benefits prepared and published by the Department of Health and approved by the Minister.

AR 202/2007 s1;198/2011;170/2012

Eligibility

2(1)  Benefits are payable in accordance with the regulations under the Act for optometric services provided to an eligible resident by an optometrist in Alberta or in the City of Lloydminster within the meaning of section 2 of the City of Lloydminster Act.

(2)  Notwithstanding subsection (1), benefits are not payable for optometric 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 set in Schedule of Optometric Benefits

3(1)  The benefits payable for optometric services are set out in the Schedule of Optometric Benefits.

(2)  Notwithstanding subsection (1), the benefits payable for optometric services provided to an eligible resident by an optometrist are limited to the lesser of

                               (a)    the amount claimed, and

                              (b)    the rates established in the Schedule of Optometric Benefits.

Benefits to include amounts for specific services

4   The benefits payable for optometric services provided to an eligible resident by an optometrist include an amount for the following:

                               (a)    performing the optometric services and any service, item or expense that supports or is a necessary adjunct to the performance of those services;

                              (b)    administration and overhead expenses, including expenses for premises, equipment, supplies and personnel;

                               (c)    obtaining consents and recording of information regarding the optometric services provided unless the recording of the information is for the purposes of a third party;

                              (d)    the technical and interpretation components of the optometric services however, in the case of CAVF tests, retinal imaging and internal retinal photography, the technical and interpretation components of the test are payable as separate amounts;

                               (e)    completing and submitting claims;

                               (f)    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 (AR 76/2006).

AR 202/2007 s4;186/2014

Benefits not payable

5   Benefits are not payable under the Alberta Health Care Insurance Plan for optometric services where

                               (a)    the Alberta College of Optometrists requires its members to have particular skills, training, education, certification, accreditation or approval prior to providing those services, and

                              (b)    the optometrist providing those optometric services has not met those requirements.

Part 2
Eligible Residents who are
Seniors and Children

Definition

6   In this Part, “eligible resident” means a resident of Alberta who is

                               (a)    65 years of age or older, or

                              (b)    18 years of age or younger.

Optometric services

7   For the purposes of this Part, the following services are specified as basic health services and as optometric services:

                               (a)    complete oculo‑visual assessment, including refraction and writing of optical prescription for the fitting of corrective lenses;

                              (b)    partial vision examination, which includes 2 or more diagnostic procedures listed in clause (c);

                               (c)    the following diagnostic procedures:

                                        (i)    external examination;

                                      (ii)    internal examination;

                                     (iii)    tear‑chemistry evaluation;

                                     (iv)    anterior chamber depth measurement;

                                       (v)    tonometry;

                                     (vi)    colour vision testing;

                                    (vii)    visual fields testing;

                                   (viii)    refraction;

                                     (ix)    examination for low vision aid;

                                       (x)    repealed AR 186/2014 s3.

AR 202/2007 s7;186/2014

Benefit limits

8(1)  An eligible resident is entitled to have benefits paid for

                               (a)    the optometric services specified in section 7(a) and (b), and

                              (b)    one of the diagnostic procedures listed in section 7(c)

once in a benefit period, unless this section provides otherwise.

(2)  An eligible resident is entitled to have benefits paid for the optometric services referred to in subsection (1) more than once in a benefit period

                               (a)    if the eligible resident has been referred to the optometrist by a physician or nurse practitioner, or

                              (b)    if the Minister considers that the limit is not appropriate based on the nature of the condition or episode of illness or trauma of the eligible resident.

(3)  An eligible resident is entitled to have benefits paid for the optometric services referred to in subsection (1) one additional time in a benefit period if the condition or episode of illness or trauma is related to one of the following:

                               (a)    diabetic instability;

                              (b)    eye infection or inflammation;

                               (c)    glaucoma;

                              (d)    cataract;

                               (e)    progressive myopia;

                               (f)    corneal health analysis, including corneal abrasion or trauma, recurrent corneal erosions or following surgery for the eye causing corneal health problems;

                               (g)    post‑operative examination carried out by another practitioner in a different community, after the 14‑day post‑operative period;

                              (h)    post‑operative examination carried out in the same community after the 14‑day post‑operative period;

                               (i)    neuromuscular imbalance;

                               (j)    intraocular hemorrhages;

                              (k)    a physician or nurse practitioner has advised the resident to have an eye examination because the resident has headaches;

                               (l)    presence of superficial foreign body in the eye;

                             (m)    an ocular anterior segment disorder requiring the administration of and a prescription for a therapeutic pharmaceutical agent.

(4)  Subject to section 9, if more than one of the optometric services referred to in subsection (1) is provided to an eligible resident on a single day, the eligible resident is only entitled to have benefits paid for one of the services provided on that day.

AR 202/2007 s8;198/2011

Benefits for low vision aid tests

9   An eligible resident is entitled to have benefits paid for a low vision aid test if the test

                               (a)    is performed on the same day that an optometric service specified in section 7(a) or (b) is performed, and

                              (b)    is performed by the same optometrist who performed that service.

AR 202/2007 s9;186/2014

Part 3
Eligible Residents of All Ages

Definitions

10   In this Part,

                               (a)    “eligible resident” means a resident of Alberta;

                              (b)    “follow‑up visit” means an optometric evaluation of a patient that includes a history limited to and related to the presenting problem, including all appropriate diagnostic tests and procedures, advice to the patient and a written prescription, if required;

                               (c)    “initial visit” means an optometric evaluation of a patient, including all appropriate diagnostic tests and procedures, advice to the patient and a written prescription, if required.

AR 202/2007 s10;331/2009;37/2010;198/2011

Optometric services

11   For the purposes of this Part, the following services are specified as basic health services and as optometric services:

                               (a)    initial visit;

                              (b)    follow‑up visit;

                               (c)    CAVF test.

AR 202/2007 s11;331/2009

Benefit limits

12(1)  In each benefit period, an eligible resident is entitled to have benefits paid for a maximum of one initial visit and, if considered necessary by an optometrist, one follow‑up visit for each mutually exclusive condition or episode of illness or trauma

                               (a)    if the eligible resident

                                        (i)    has been diagnosed with diabetes mellitus by a physician or nurse practitioner,

                                      (ii)    is taking a drug

                                              (A)    that has been prescribed by a physician or nurse practitioner,

                                              (B)    for which it is standard care to regularly monitor for ocular side effects, and

                                              (C)    that is specified in section 3.3 in the Schedule of Optometric Benefits,

                                           or

                                     (iii)    has been referred to the optometrist by a physician or nurse practitioner,

                                  or

                              (b)    if the condition, illness or trauma is specified in section 4.1 of the Schedule of Optometric Benefits.

(2)  A claim for benefits for a follow‑up visit referred to in subsection (1) that is performed within 90 days of the initial visit must be accompanied with explanatory text unless the eligible resident’s eye care is subject to a co‑management arrangement under section 14.

(3)  In each benefit period, an eligible resident is entitled to have benefits paid for a maximum of one initial visit, one follow‑up visit and, if considered necessary by an optometrist, 2 repeat follow‑up visits for each mutually exclusive condition or episode of illness or trauma if the condition, illness or trauma is specified in section 4.2 of the Schedule of Optometric Benefits.

(4)  Despite subsection (3), if the condition, illness or trauma is specified in section 4.3 of the Schedule of Optometric Benefits, there is no limit on the number of repeat follow‑up visits.

AR 202/2007 s12;331/2009;198/2011

Benefit for CAVF test

13(1)  An eligible resident is entitled to have benefits paid for a CAVF test performed in conjunction with another optometric service

                               (a)    if a CAVF test is considered necessary by an optometrist, and

                              (b)    whether the CAVF test and the other optometric service are performed on the same day or on different days.

(2)  A claim for benefits under subsection (1) must be accompanied with explanatory text unless

                               (a)    the eligible resident’s illness, condition or trauma is related to glaucoma, retinal detachment or neurological disorder, or

                              (b)    the eligible resident is

                                        (i)    65 years of age or older, or

                                      (ii)    18 years of age or younger.

AR 202/2007 s13;186/2014

Benefits for internal retinal photography
and retinal imaging

13.1   An eligible resident is entitled to have benefits paid for internal retinal photography and retinal imaging if the test is not included in an initial or follow-up visit.

AR 186/2014 s6

Co‑management arrangement

14(1)  An individual’s eye care may be subject to a co‑management arrangement between an ophthalmologist and an optometrist.

(2)  The following rules apply where an individual’s eye care is the subject of a co‑management arrangement:

                               (a)    there is no limit on the number of follow‑up visits for which benefits are payable;

                              (b)    every claim for benefits submitted by an optometrist arising from a co‑management arrangement must be accompanied with the practitioner identification number of the ophthalmologist;

                               (c)    evidence of a co‑management arrangement, such as a referral letter from the ophthalmologist and ongoing communication between the optometrist and the ophthalmologist, must be available and provided upon the Minister’s request.

Billing rules for Part 3

15(1)  Every claim for benefits under this Part must

                                       (a)    identify the optometric service provided,

                                       (b)    subject to subsection (2), identify the diagnostic code for that service as specified in the Schedule of Optometric Benefits, and

                                       (c)    include the practitioner identification number of the optometrist and of the referring physician or nurse practitioner, if any.

(2)  Subsection (1)(b) does not apply to a claim for benefits referred to

                               (a)    in section 12(1)(a)(ii), or

                              (b)    in section 12(1)(a)(iii), unless the optometrist has diagnosed a condition or episode of illness or trauma.

(3)  Subject to section 13(1), if more than one of the optometric services set out in section 11 is provided to an eligible resident on a single day, the eligible resident is only entitled to have benefits paid for one of the services provided on that day.

AR 202/2007 s15;331/2009;186/2014

Services for which no benefits payable

16   For the purposes of this Part, no benefits are payable under the Alberta Health Care Insurance Plan in respect of the following services:

                               (a)    routine eye exams, including assessment for refractive changes;

                              (b)    routine or baseline computer assisted visual fields screening;

                               (c)    external ocular photography;

                              (d)    contact lens fitting;

                               (e)    spectacle treatment services;

                               (f)    vision training or vision therapy (orthoptics);

                               (g)    corneal topography;

                              (h)    contrast sensitivity;

                               (i)    electrodiagnostic procedures;

                               (j)    punctal occlusion procedures;

                              (k)    services provided subsequent to other services not covered by the Plan (i.e. photo‑refractive keratectomy ‑ PRK);

                               (l)    third party initiated eye exams;

                             (m)    services required as a condition of employment;

                              (n)    services pertaining to work related injuries covered by WCB;

                              (o)    verification of prescriptions filled out of office;

                              (p)    exams or services for providing a second opinion;

                              (q)    completion of forms, reports or letters;

                               (r)    group screening;

                               (s)    missed appointments;

                               (t)    GDX technologies.

AR 202/2007 s16;186/2014

Part 4
Repeal, Expiry and
Coming into Force

Repeal

17   The Optometric Benefits Regulation (AR 85/2006) is repealed.

Expiry

18   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 September 30, 2019.

AR 202/2007 s18;186/2014

Coming into force

19   This Regulation comes into force on October 1, 2007.