INTENT

To provide coverage for essential medical and surgical supplies required for health and well-being, when no other resource can provide the needed items.

POLICY

Income Support (IS) provides essential medical and surgical supplies when a physician indicates the item is essential for the medical management of the client’s condition and:

• It is not available or normally covered through any other resource such as Alberta Aids to Daily Living (AADL), the Residential Access Modification Program (RAMP), Family Supports for Children with Disabilities (FSCD), hospital, clinic, therapist, community resource or agency and

• No lower-cost alternative can be accessed. Fixed rates have not been established for any medical and surgical supplies with the exception of wheelchair/scooter repairs and batteries. At least two written quotes should be obtained for any items costing $1,000 or more.

Substantiation
Documentation from a physician indicating the item is essential for the medical management of the client’s condition is required. Coverage for all benefits under medical and surgical supplies must be pre-approved by the worker. Reimbursements should not be made unless the item was required in an emergency and approval was sought as soon as possible after the emergency.

Requests for Continuous Positive Airway Pressure (CPAP) Machines require more extensive substantiation for consideration.

Rate 
Items covered by IS under Medical and Surgical Supplies must:

• Be a consumable (one-time use or disposable) product or supply with a total value of $791.00 or less per month (e.g., Lifeline if client otherwise qualifies, allergy serum where not available through the pharmacy, skin testing materials, bandages) or
• Be a durable item (have a useful life of more than three months) and its cost must not exceed $2,258.00 (e.g., IUD, humidifier, back supports, wrist brace).
  
  

Wheelchair/Scooter Repairs and Batteries
IS covers the actual costs for repairs and batteries for privately owned wheelchairs and scooters up to the maximum rates (includes labour and shipping):

• Manual wheelchair repairs: $498.00 per year
• Power wheelchair repairs: $664.00 per year
• Scooter repairs: $664.00 per year
• Batteries for power wheelchairs and scooters: $664.00
  
  

Clients must use other resources whenever possible. For example, short-term medical needs (six months or less) may be available through community resources and agencies (e.g., Red Cross, Easter Seal) that loan medical supplies, such as crutches, canes, walkers, wheelchairs, hospital beds and T.E.N.S. machines. Each area office should be familiar with the resources within their community.

Alberta Aids to Daily Living (AADL) may cover benefits for Albertans who have a long-term disability (6 months or more), and chronic and severe conditions. Detailed information on AADL benefits can be found in the AADL Program Manual.

The client is responsible for contacting an AADL authorizer or their Regional Health Authority’s Home Care Program to be assessed by an AADL authorizer. The authorizer will assess the client’s needs and eligibility for AADL medical equipment and/or supplies, and complete an AADL authorization form. If the request is approved, the client presents the health benefits card to the vendor as proof of exemption from the AADL 25% co-pay.

AADL provides coverage only for items listed in their program manual. AADL does not have an appeal mechanism to request coverage for an item not listed in their manual, and does not replace lost or stolen equipment, or equipment damaged due to misuse.

AADL does have an appeal process to review requests outside their quantity and frequency limits for items that they normally cover e.g. incontinent supplies. If the AADL Quantity and Frequency Review Committee denies a request, consultation should occur with AADL to explore the reasons for denial and other alternatives before the IS worker considers providing the requested item.

For more information on coverage criteria please contact AADL at 780‑427‑0731 in Edmonton or toll free in Alberta at 310‑0000, then 780‑427‑0731.

Family Supports for Children with Disabilities (FSCD) will assist children under the age of 18 with a diagnosed disability. FSCD can assist only with the cost of necessary equipment related to the child’s disability. For more information please contact the FSCD Information line at 780‑644‑1636 or the nearest local office for more information.

Appeals
Medical and surgical supplies are provided under the authority of the Minister Income Support, Training and Health Benefits Regulation, Schedule 4, section 27 and appeal panels have no authority to rule with respect to them.

However, if the item requested does not meet all the policy or coverage criteria, and denial of this item would create a life-threatening situation or debilitating effect, Director Approval may be sought. 

PROCEDURES

When a worker receives a request for coverage of medical and surgical supplies, the worker:

1. Reviews the medical documentation submitted to confirm medical need.
2. Consults the AADL program or any other relevant programs e.g. the Residential Access Modification Program and/or Family Supports for Children with Disabilities to confirm they do not cover the item requested.
3. Reviews the Scratch Pad to ensure the client has not reached their monthly maximum for consumable goods.

   and if eligible,

4. Notifies the vendor to proceed.

The vendor then sends an invoice that includes the client’s name, file number, and itemized list of costs. The worker adds the benefit to the Scratch Pad and records the details and amounts issued.

Benefits approved for coverage under medical surgical supplies are provided either by cheque to the client or, EMP 0018 Purchase Authorization and Invoice (printer voucher) or EMP 0018HW Purchase Authorization and Invoice (handwritten voucher) to the vendor and are coded as follows:

Need Code
1721  Continuous Medical Needs
1912  Medical/Surgical Supplies