Medically Necessary FAQ for Patients
These questions were submitted by real Albertans. If you have a question you would like to see posted in the FAQ, please send it to alberta.association@optometrists.ab.ca We will do our best to reply to your question within 48 hours.
- I am between the ages of 19-64. Are my regular eye exams now covered under by Alberta Health?
- My family has a history of an eye disorder or disease. Are my annual exams now covered by Alberta Health?
I am between the ages of 19-64. Are my regular eye exams now covered by Alberta Health?
No. Albertans ages 19-64 are still responsible for the payment of their regular annual eye exams. Only medically necessary procedures and exams are covered for this age group.
I suspect that I have a medically necessary condition. If I book an eye exam, will the exam be covered by Alberta Health whether or not I am actually diagnosed with a condition?
Yes. All emergency eye care for injuries, eye infections, flashes and floaters are now covered by Alberta Health Care regardless of the final diagnosis. It is important to note, however, that in almost all cases a refraction for prescription eye glasses is not considered a medically necessary procedure.
My family has a history of an eye disorder or disease. Are my annual exams now covered by Alberta Health?
No. Family history of a disorder does not automatically qualify someone for coverage by Alberta Health. Every person who has a routine eye exam has his or her vision and eye health checked and screened for all possible diseases and disorders. If a disorder or disease is actually diagnosed, then treatment will be covered as necessary.
I am a diabetic. Are my annual routine eye exams now covered by Alberta Health?
For diabetic Albertans aged 19-64, your annual “bumper to bumper” eye exam (which includes measuring for new prescription glasses or contacts) is not covered by Alberta Health. Seniors and children are always covered for their annual eye exam whether they are diabetic or not.
As a diabetic, if my routine eye exams aren’t covered by Alberta Health, what is?
The diabetic eye health exam is covered and consists of an acuity measurement, eye pressure measurement, dilated fundus exam, and slit lamp exam. If there are other diabetic complications occurring, then additional testing may be done. If you're vision is fluctuating, this is covered. The provision of a prescription for glasses is not covered.
I recently had cataract surgery. Because of the surgery, I suspect that my prescription has changed. Will my exam for a new prescription be covered by Alberta Health?
Possibly. Your ophthalmologist who performed the surgery should refer you to a co-managing optometrist (this can be your regular optometrist). The optometrist will do post-operative assessments at two and six weeks after the surgery. Those assessments may include a refraction (prescription), which will be covered by AHC as it is a result of the surgery.
If you do not have a referral from your ophthalmologist, however, the optometrist may not be able to bill Alberta Health for the refraction. It is important to speak to your ophthalmologist and get a referral before visiting an optometrist for post-operative care.
Are my prescription eye drops covered by Alberta Health now?
No. Only medically necessary procedures are covered. The prescription costs are still the responsibility of the patient. Continue to fill your prescriptions as you always have, or talk to your employer about your office medical benefits. If you are not under an employee health plan, organizations such as Alberta Blue Cross offers plans that may suit your needs.
For medically necessary services, are fees direct billed to Alberta Health or do we (the patients) pay upfront and send the claim to Alberta Health for reimbursement?
Your optometrist bills Alberta Health directly for any medically necessary procedures performed. There is no cost to you, the patient. Naturally, it is always a good idea to ask your optometrist if there will be any charge to you before you begin the exam.
