Health Benefits Exception Committee (HBEC)

Published Date: November 23, 2011
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Policy

The HBEC makes decisions regarding goods/services which could reasonably be considered a drug, a dental, optical, or ambulance service, or diabetic supplies and which are not listed in, or which are outside the terms of the agreements or drug benefit lists approved by the Minister.

Clients should attempt to access all other potential methods of authorization (first avenue of authorization), as identified in the following Authority Chart.

Only the following goods/services are considered a health benefit.

Type of Benefit Requested First Avenue of Authorization HBEC Authority to Make Decision Outside Agreements
Prescription and non-prescription drugs, vitamins and other nutritional products ABC Special Authorization
(If appropriate)
Yes
Optical exams, eyeglasses and contact lenses Supervisor may authorize eye exams and replacement eyeglasses by Repayment Agreement Yes
Dental exams, procedures, dentures, and appliances such as bruxism splint Supervisor may authorize replacement dentures by Repayment Agreement ADSC Review Committee Yes
Ambulance IS Specialist for BFE clients with a severe handicap Yes
Diabetic Supplies N/A Yes

The following health related goods/services are not health benefits under ISTHB Regulation Section 73. They may however be authorized by Director Approval as shown in the Table. Requests for these items should be submitted to the appropriate Director/Regional Director/Area Manager and not to the HBEC.

Type of Benefit Requested First Avenue of Authorization HBEC Authority to Make Decision Outside Agreements Director Authority to Make Decision Outside Policy
Special Diets Worker has authority to issue special diets listed in policy No Yes – Executive Director, Employment and Financial Services, Program Policy 
CPAP devices Worker has authority within policy No Yes – Regional Directors/Area Managers
Supplies or repairs to existing CPAP devices Worker has authority within policy rules (Medical/Surgical Supplies) No Yes – Regional Directors/Area Managers
Wheelchair repairs Worker has authority within policy rules (Medical/Surgical Supplies) No Yes – Regional Directors/Area Managers
Other Medical/Surgical Supplies Worker has authority within policy No Yes – Regional Directors/Area Managers
Alternative and Complementary Health Therapies such as chiropractic, acupuncture and massage NA No Yes – Regional Directors/Area Managers

Eligibility for health benefits governed by agreements or drug benefit lists is generally confirmed by the benefit administrator (Alberta Blue Cross and Alberta Dental Services Corporation) and communicated by them to the vendor. When clients request health benefits, workers may need to confirm eligibility, and inform the client if they are not eligible.

Note
If in doubt whether or not a requested good/service is governed by the agreements or drug benefit lists, and under the authority of the HBEC to make a decision, contact the Health Benefits Planner responsible for the HBEC at 780-415-9432.

The worker attempts to resolve the issue whenever possible by explaining applicable sections of the IESA, regulations, policy, and/or agreements, and by discussing alternative resources. Effort should be made to resolve issues by other means prior to submitting a health benefits exception request to the HBEC.

When the matter is not a benefit request, but rather one of financial eligibility (e.g. client’s income is higher than the qualifying income level for the ACHB or the AAHB), the matter is subject to appeal to an appeal panel, and the appeal policy and procedure must be followed.

Notification
Whenever a client requests a health benefit not listed in, or outside the terms of the agreements or drug benefit lists is denied, the worker must advise the applicant or recipient of the following:

  • Their right to request a health benefit exception decision by the HBEC and
  • The exception process and
  • The time limit to request an exception.

Notification may be given verbally or in writing but there must be documentation or a copy of the letter on the client’s file confirming the notice.

The worker provides the client with form AEHB 3487 HBEC Request for a Health Benefit Exception. This is the preferred method to initiate a HBEC exception request; however, any form of written request is acceptable. Under no circumstances, should clients be advised to phone or contact in person a HBEC member or a Health Benefits Planner.