ISTHB Regulation, Section 73(2)(c) provides authority for coverage of optical benefits in accordance with agreements with the Alberta Association of Optometrists, and the Alberta Opticians Association.

These optical agreements can be accessed on the ministry intranet.

INTENT

To provide optical benefits to eligible children and adults to ensure they have access to optical goods and services essential to health, well-being, and participation in school and work.

POLICY

Definitions

Optometrists perform eye exams, prescribe and dispense glasses and contact lenses. Medically required eye exams performed by an optometrist are covered by Alberta Health (AH).

Opticians dispense glasses and contact lenses someone else has prescribed.

Ophthalmologists are medical doctors who specialize in eye diseases. AH covers ophthalmologist examination services.

Eye Examination

Community and Social Services provides payment for routine eye examinations performed by an optometrist, for adults and 19-year-old dependants of Income Support and AAHB recipients. The frequency limit is one routine eye examination per adult every two years, and once per year for 19-year-old dependants.

Alberta Health provides payment for all eye examinations performed by an ophthalmologist under the Alberta Health Care Insurance Plan (AHCIP). AHCIP also covers routine and medically required eye examinations performed by an optometrist for children under 19 years old, and persons 65 and older.

AHCIP provides payment for medically required exams performed by an optometrist, for Albertans aged 19 to 64 if they:

• have diabetes or hypertension as diagnosed by a physician
• have cataracts, glaucoma, ‘red eye,’ or retinal disease;
• require a foreign object to be removed from their eye;
• are taking Hydroxychloroquine Sulfate (Plaquenil) as prescribed by a physician
• have been referred by a physician or nurse practitioner; or
• have any other specific disease, illness or trauma listed in the Optometric Procedures List.

Eye Glasses

The agreements set out fixed prices for single lens, bifocal lens and trifocal lens eyeglasses. Eye condition must vary at least .5 dioptres from normal before initial eyewear is issued.

One pair of eyeglasses for distance and one pair for reading are allowed when substantiated by prescription and a bifocal cannot be worn.

Frequency Limits

• Children under age 18, or under 20 if attending school (K-12) and living with their parents/guardian, may receive one pair of eyeglasses or one repair to existing eyeglasses every 12 months.
  
• Adults may receive one pair of eyeglasses or one repair to existing eyeglasses every 24 months.
  
• Frequency limits are not affected by a file opening or closing during the benefit period.
  
• Any time there is a change in prescription of at least plus or minus .5 dioptres, then a new lens(es) may be provided.

The agreements provide for a one-year limited manufacturer’s warranty on the frames against breakage. The warranty does not cover situations where the breakage is attributed to client abuse or neglect.

Additional Repairs and Replacement

If the client has an additional request for repairs or replacement eyeglasses within the benefit period, and warranty coverage is not applicable, then

• The Health Benefits Exception Committee (HBEC) can hear the request in cases where the eyeglasses were broken or lost through no fault of the client (e.g. fire, theft, physical attack by another party), or
  
• The supervisor may authorize repairs or replacement eyeglasses and an eye exam if required, at the contracted rates, by Repayment Agreement in cases of neglect or abuse, and where
  
  • The good or service requested is the most cost effective, and no other resources are available, and
  • The client signs an EMP 976B Repayment Agreement.

Contact Lenses

Community and Social Services pays for contact lenses provided they are prescribed by an ophthalmologist or optometrist and the following medical conditions exist:

• Aphakia
• Corneal Irregularities
• Astigmatism which is inadequately corrected by eye glasses
• Refractive errors in excess of plus or minus 7.00 dioptres in any meridian

Clients who have contact lenses may be allowed a back-up pair of glasses, as contact lenses cannot be worn on a continuous basis. Cleaning solutions for contact lenses are not covered as a benefit.

Disposable contact lenses may be covered in place of the non-disposable lenses when the disposables are the least cost alternative. Clients must meet the criteria for contact lenses in order to be covered for the disposable lenses.

Frequency Limits for Contact Lenses

• Children under age 18, or under 20 if attending school (K-12) and living with their parents/guardian, one pair every 12 months
• Adults, one pair every 24 months
• Frequency limits are not affected by a file opening or closing during the benefit period

Replacement and Repayment of Contact Lenses

Within the Optician and Optometrist Agreements, clients with HBC coverage are allowed:

• Replacement contact lenses in cases where there is a change in prescription of at least plus or minus .5 diopters
  

If the client has an additional request for replacement contact lenses within the benefit period, then

• The Health Benefits Exception Committee can hear the request in cases where the contact lenses were lost or damaged through no fault of the client (e.g. fire, theft, physical attack by another party), or
  
• The supervisor may authorize replacement contact lenses and an eye exam if required, at the contracted rates, by Repayment Agreement in cases of neglect or abuse, and where
  • The good or service requested is the most cost effective, and no other resources are available, and
  • The client signs an EMP 976B Repayment Agreement.

Progressive Lenses

Coverage for progressive (no-line) lenses is provided in place of lined trifocal lenses when the progressive lenses are the least cost alternative.

Tinting, Transition Lenses, and High Index Lenses

The agreements contain clinical criteria for issuing these items.

Tinting:

Community and Social Services pays for tinting providing it is prescribed by an opthalmologist or optometrist and at least one of the following medical conditions exists:

• Aphakia
• Kerato-conjunctivitis (chronic)
• Iritis
• Xerosis of the cornea (mild chronic)
• Adverse effects of prescribed drugs
• Partial aniridia

Written clinical rationale must be provided on the billing form.

Transition Lenses:

Community and Social Services pays for transition lenses when necessary and prescribed by an ophthalmologist or optometrist.  The criteria for prescribing transition lenses are the same as the criteria for tinting.

Written clinical rationale must be provided on the billing form.

High Index Lenses:

Community and Social Services pays for high index lenses providing they are prescribed by an ophthalmologist or optometrist, and the prescription meets the minimum criteria in any meridian of + or - 6.00 dioptres.

Written clinical criteria must be provided on the billing form.

Appeal and Health Benefits Exception Committee

Decisions regarding optical benefits provided as a Community and Social Services health benefit are defined in Regulations as decisions of the Minister, and therefore, an appeal panel does not have authority to overturn a decision regarding health benefits provided under Part 2 Division 2 of the IESA, and under ISTHB Regulation, Section 73.

If ABC denies approval of any exceptional service or item required by a client or their dependant outside of the Optical Agreements, or the optician/optometrist determines the need is outside the agreements, the client is referred back to their worker. The vendor or service provider should provide the client with the following information:

• Description of services or benefit being requested, and
• Rationale for the additional optical/optometric need, and
• Other alternatives that are available within the existing agreements, and
• Detailed cost breakdown.

The client may request a review, and decision on the optical good or service, by the Community and Social Services-Health Benefits Exception Committee (HBEC). If the request is for replacement eyewear and due to client negligence, the supervisor may authorize replacement by Repayment Agreement, rather than sending the request to the HBEC.

PROCEDURE

Optical service vendors must obtain pre-authorization through Alberta Blue Cross (ABC) before providing services to Community and Social Services clients. This will ensure the frequency limits and clinical criteria are enforced. ABC administers the terms of the agreements and the payment for all optical goods and services.

Optometrists and Opticians send their pre-authorizations and claim forms to:

Alberta Blue Cross
10009 – 108 street
Edmonton, AB   T5J 3C5

Fax: 780-498-3544

Clients should be advised that optical vendors must obtain pre-authorization from ABC prior to providing optical services. Clients must produce their HBC, Learners Health Benefit Card or Alberta Child Health Benefit Card to the vendor.

An EMP 0018 Purchase Authorization and Invoice (Voucher) is only used for the following circumstances:

• If a Health Benefits Card has not yet been issued or a dependant was added to the file after the card was issued and the service is urgently required before the next card is received.
• For One-Time Issue recipients (client sub-type 81 and 82).

The EMP 0018 Purchase Authorization and Invoice:

• Is issued to the optometrist or optician
• Is forwarded by the optometrist or optician to Alberta Blue Cross for payment, 
• Has no dollar amount, 
• Is used only for services covered in the Agreements, or approved by the Health Benefits Exception Committee.

Service Description for Optometrist and Optician Services

The appropriate Goods Code, Need Code and Description for the Optometrist or Optician service must be included on the EMP 0018 Purchase Authorization and Invoice. The period in the description must be the same as the Period of Assistance on the EMP 0018 Purchase Authorization and Invoice, and must cover the dates of service on the vendor’s claim form.

Procedure for Replacement Eyeglasses or Contact Lenses and Eye Exams

When:

• replacement glasses/contact lenses or an eye exam are required but the supervisor believes a Repayment Agreement is not appropriate, or
• the client refuses to sign a Repayment Agreement, then the client can request approval from the Health Benefits Exception Committee using the regular HBEC process. Workers should ensure that clients provide the circumstances around the need for replacement eyeglasses or lenses with their request. Not providing these circumstances will likely delay the decision.

Alternately, for optical requests only, requests to the Health Benefits Exception Committee can also be sent by email. The supervisor or worker sends an email to the Health Benefits Manager or designate. The email must provide the following information:

• Client name
• Family member requiring the replacement glasses/contacts if different from client
• File number
• Vendor info (name, address and phone number) – this is required by ABC so they can notify the vendor in a timely manner
• Reason glasses/contacts need replacement and extenuating circumstances which indicate client is not at fault (e.g. client fell due to epilepsy, client assaulted, glasses lost/stolen while client in hospital/shelter/ambulance, or mental health issues)
• What is required (i.e. frames, lenses, eye exam, contact lenses) 
  
  Note
  If a client requests a type of frame or lens not covered by the Optical Agreement then the regular HBEC process is required (i.e. medical documentation to support the request).

When optical benefits are requested without a Repayment Agreement, the Health Benefits Manager or designate:

• presents the request to the Health Benefits Exception Committee for a decision
• advises Alberta Blue Cross if the HBEC decision is to approve the request
• advises the area office of the decision
• sends a copy of the HBEC written decision to the client

ABC notifies the vendor of the approval.

Procedure for Supervisor Approval by Repayment Agreement

Following the signing of the repayment agreement:

• the supervisor notifies Alberta Blue Cross that coverage for an eye exam and/or replacement eyeglasses or contact lenses is approved, by email to:
  govapp@ab.bluecross.ca
• the email must include:
  
  • "Supervisor Approval for Optical Benefits" in the subject line
  • the optical benefit approved
  • client name (HH on file)
  • file number
  • spouse/child name if the benefit is for the spouse or child
  • name, address, and telephone number of the optical vendor
  • the supervisor's name, title, and contact information

• supervisors consult the optical agreements for the correct repayment amount(s)

ABC notifies the vendor of the approval.