What Alberta Health Covers at a Family Medicine Clinic

One of the more common questions patients ask is whether a service is covered by their Alberta health card.

The basic rule is fairly simple: the Alberta Health Care Insurance Plan, or AHCIP, covers medically necessary care provided by a physician. It does not cover every service that happens inside a medical clinic.

Here is what patients should know before their appointment.

What does AHCIP cover?

AHCIP provides eligible Alberta residents with full coverage for medically necessary physician services.¹

At a family medicine clinic, insured services commonly include:

• Assessment of a new illness or injury
• Follow-up of an ongoing medical concern
• Management of chronic conditions such as diabetes, high blood pressure, asthma or heart disease
• Mental health assessment and treatment provided by a physician
• Well-child and developmental care
• Prenatal and postpartum medical care
• Preventive care and age-appropriate screening
• Medication reviews
• Referrals to specialists
• Review of medically relevant test results
• Medically necessary office procedures
• Ordering medically required laboratory tests, imaging and other diagnostic investigations

The physician's time spent assessing you, making a diagnosis, discussing treatment and writing a prescription is generally part of the insured visit. The medication you pick up from the pharmacy is a separate matter and is usually not covered by AHCIP.¹

For an insured appointment, bring your Alberta health card and government-issued photo identification. The clinic may ask to confirm your address, telephone number and other registration information.¹

What does "medically necessary" mean?

There is no single list that captures every possible situation.

In general, a service is medically necessary when it is provided to assess, diagnose, treat or appropriately monitor your health. The decision depends on the reason for the visit, the physician's clinical judgment and Alberta's Schedule of Medical Benefits.

For example, an appointment to assess chest pain, review worsening depression, monitor diabetes or investigate a new lump would generally be insured.

A report requested by an insurance company may use medical information, but the report itself exists for the insurer rather than for your treatment. That is usually an uninsured service.

This is why two services involving the same medical condition may be treated differently. The appointment to assess and treat your back pain may be covered. A detailed disability form describing how the back pain affects your ability to work may not be.

Are physical examinations covered?

The phrase "physical exam" can refer to several different things.

A medically necessary examination performed as part of assessing a symptom or condition is insured. A comprehensive health assessment may also be insured when it is clinically appropriate.

However, family medicine has moved away from giving every patient the exact same head-to-toe examination and set of tests each year. Preventive care is usually tailored to your age, medical history, family history, medications and individual risk factors.

Depending on the patient, preventive care may include:

• Blood pressure measurement
• Cervical screening
• Colorectal cancer screening
• Breast cancer screening
• Diabetes or cholesterol testing
• Vaccination review
• Smoking, alcohol and substance-use screening
• Sexual health care
• Mental health screening
• Review of diet, exercise, sleep and other health risks

A physical examination requested for employment, insurance, sports participation, a driver's licence or another third-party purpose is generally not covered by AHCIP, even though a physician must perform it.¹

Are laboratory tests and medical imaging covered?

Medically required laboratory tests, X-rays and other diagnostic procedures are generally insured when appropriately ordered.¹

That does not mean every test a patient requests will automatically be covered or medically appropriate. Your physician may recommend against a test when it is unlikely to provide useful information, carries a risk of misleading results or is not supported by current evidence.

Some tests offered through private companies may fall outside Alberta's publicly funded system. Ask before proceeding if you are uncertain.

Are medications covered?

AHCIP does not generally pay for prescription medications obtained outside a hospital.¹

Many people have medication coverage through an employer plan, private insurer, federal program or an Alberta government benefit program. Alberta also offers supplementary drug programs, including Non-Group Coverage and coverage for eligible seniors.²

Even when the appointment is insured, you may still have to pay for:

• Medication dispensed by a pharmacy
• A medication administered in the clinic
• Certain vaccines
• Medical supplies
• Dressing materials
• Devices or braces
• The portion of a drug cost not covered by your benefit plan

The clinic should tell you about any clinic charge before providing the item or service.

Are vaccines covered?

Coverage depends on the vaccine and why it is being given.

Many routine, publicly funded immunizations are available through Alberta's immunization programs. Travel vaccines and travel-health consultations are commonly uninsured. Some vaccines may be recommended medically but still require payment by the patient or their private insurance plan.¹³

Ask the clinic or pharmacy about the expected cost before booking a travel consultation or receiving a vaccine that is not part of the routine public program.

Are mental health services covered?

Mental health assessment and treatment provided by a family physician or psychiatrist are insured when medically necessary.¹

This can include:

• Assessment of anxiety, depression and other mental health concerns
• Medication management
• Supportive counselling provided as part of physician care
• Monitoring symptoms and treatment response
• Referral to psychiatry or other mental health services

Visits with a private psychologist or counsellor are not generally covered by AHCIP, although they may be covered through workplace benefits, private insurance, government programs or services available through a Primary Care Network.¹

Are procedures covered?

Some office procedures are insured when they are medically necessary. Others are uninsured because they are cosmetic, elective or specifically excluded from provincial coverage.

For example, a skin biopsy to investigate a suspicious lesion may be insured. Removing a harmless lesion solely because a patient does not like its appearance may be considered cosmetic and may carry a fee.

Coverage can also vary for procedures such as:

• Wart treatment
• Skin-tag removal
• Circumcision
• Cosmetic injections
• Joint injections

The physician's service may be insured while a medication, device or supply used during the procedure has a separate cost. Because coverage depends on the exact procedure and medical reason, ask the clinic before the appointment if you are uncertain.

What services are usually not covered?

Alberta lists several common services that fall outside AHCIP coverage, including third-party medical examinations, forms and notes, driver's medical examinations, non-medically necessary cosmetic procedures, most prescription drugs outside hospital and travel vaccines.¹

At a family clinic, common uninsured services may include:

• Driver's medical examinations
• Pre-employment or employer-requested medical examinations
• Insurance forms
• Disability forms and attending physician statements
• Legal reports
• Sick notes
• Work or school notes
• Fitness-to-participate forms
• Sports medical examinations requested by an organization
• Travel health consultations
• Travel vaccines
• Transfer or copying of medical records
• Cosmetic procedures
• Some elective or de-insured procedures
• Telephone prescription renewals that do not qualify as an insured medical service
• Missed-appointment or late-cancellation fees

It does not matter whether the patient, employer, insurer, school or lawyer asks for the paperwork. The relevant question is whether the service is medically necessary care covered by AHCIP or an administrative service provided for another purpose.

Why do forms and notes have fees?

Completing a form often takes more work than patients realize.

The physician may need to:

• Review several years of medical records
• Confirm diagnoses and treatment history
• Review specialist reports and test results
• Assess current functional limitations
• Decide whether the information requested can be supported medically
• Complete several pages of questions
• Prepare an accompanying report
• Ask clinic staff to copy or send supporting documents
• Take responsibility for the accuracy of the information provided

AHCIP does not pay the physician or clinic for most of this work. Fees help cover the physician's professional time, administrative work, staff time, supplies and clinic overhead.³

A short note will usually cost less than a detailed disability application or multi-page insurance report because the amount of work is different.

Fees are not fixed across Alberta. The Alberta Medical Association publishes guidance, but individual physicians and clinics set their own fees. Costs can therefore vary between clinics.³

Can a clinic charge for an insured visit and a form on the same day?

Yes, an appointment can contain both an insured and an uninsured component.

For example, a physician may assess and treat a medical condition during an insured appointment and also complete a work form requested by the patient's employer. The medical care may be billed to AHCIP, while the separate administrative work may be charged to the patient or third party.

The clinic should not charge the patient for a service that is already paid for as an insured service. It should clearly explain which part is uninsured and what the fee covers.

Does the clinic have to tell me about the fee first?

Yes.

CPSA requires physicians to inform the patient or third party of the fee before providing an uninsured professional service.⁴

Fees must reasonably reflect the physician's professional costs, administrative costs and the patient's ability to pay. Physicians must also be able to explain the fee when asked.⁴

If you are unsure whether a service is covered, ask:

• Is this service covered by Alberta Health?
• Is there a separate charge for the form, medication, supply or procedure?
• Who is responsible for paying the fee?
• How much will it cost?
• Is payment required before the form is released?
• How long will it take to complete?

It is much easier to clarify this before the work is done.

What is a block fee?

Some clinics offer an optional annual block fee covering a defined group of uninsured services, such as sick notes or certain forms.

Patients must still have the option to pay for each service individually. A clinic cannot require a patient to purchase a block-fee plan before receiving insured medical care, provide preferential insured care to patients who pay it or include services that are already funded elsewhere.⁴

Anuvi does not require patients to pay a block fee to access insured medical care.

Can a physician refuse to complete a form?

A physician can only provide information and opinions that they can medically support.

Sometimes a physician needs an appointment, examination, updated testing or additional records before completing a form. A doctor may also be unable to answer questions that fall outside their expertise or are not supported by the available medical evidence.

The person or organization requesting the form does not control the physician's medical opinion. Paying a fee covers the work required to review and complete the document. It does not guarantee a particular answer, diagnosis, restriction or approval.

When possible, bring the form to the clinic well before its deadline. Detailed reports may take considerably longer than a routine appointment.

What if I cannot afford an uninsured service?

Tell the clinic before the service is completed.

Depending on the circumstances, the clinic may be able to reduce or waive the fee, arrange payment later, create a payment plan, or determine whether the organization requesting the document is responsible for the cost.

There is no guarantee that a fee will be waived, but it is reasonable to ask.

You can also check whether:

• Your employer will pay
• Your insurance company will reimburse you
• A government program covers the form
• The requesting organization has its own payment arrangement
• A shorter letter or different document would meet the requirement

What if my Alberta health coverage is not active?

Patients without active AHCIP coverage may be responsible for the cost of the medical visit itself.

This can apply to some visitors, people waiting for provincial coverage, individuals whose immigration documents have expired and patients who are otherwise not eligible for AHCIP.

Contact the clinic before your appointment if you do not have an active Alberta health card. Staff can explain the expected fee and whether another program, provincial plan or insurer may be billed.

The Main Point

Your Alberta health card covers medically necessary physician care. It does not cover every form, medication, supply, procedure or administrative service provided at a family clinic.

A useful way to think about it is:

Is the service being provided to assess or treat my health, or is it being provided mainly to satisfy an administrative, employment, insurance or personal request?

That question will often point you in the right direction, although there are exceptions.

When in doubt, ask the clinic before the service is provided. A well-run clinic should be able to explain what is covered, what is not and whether you should expect a fee.

References

1. 1.Government of Alberta. Health care services covered in Alberta. The province confirms that AHCIP covers medically necessary physician and diagnostic services and lists common exclusions, including prescription medications outside hospital, travel vaccines, third-party medicals, forms, notes and driver's medical examinations.
2. 2.Government of Alberta. Alberta Health Care Insurance Plan. Overview of AHCIP and supplementary expenses that may require other insurance, including prescription drugs, dental care and vision care.
3. 3.Alberta Medical Association. Uninsured services. Explains common uninsured services, why physicians charge fees and why fees may vary between clinics.
4. 4.College of Physicians & Surgeons of Alberta. Charging for Uninsured Professional Services. Sets requirements for advance notice, reasonable fees, consideration of ability to pay and optional block-fee programs.
5. 5.College of Physicians & Surgeons of Alberta. Can I charge a fee to complete forms, write notes or make copies of medical records for patients? Confirms that patients may be charged for uninsured services such as sick notes, records, insurance and legal forms, and driver's medical examinations.

This article provides general information about health coverage in Alberta. Coverage can depend on the specific service and circumstances. Contact the clinic or AHCIP when you are unsure whether a service is insured.