When you arrive in Edmonton and register with the Alberta Health Care Insurance Plan, one of the most important questions that arises is understanding what medical services are covered by this system. Many newcomers mistakenly believe that AHCIP covers absolutely all types of medical services and treatments because it is a public health care system. However, the reality is that although AHCIP is one of the most generous provincial health care systems in Canada, it does not cover all types of treatment.
Understanding what AHCIP covers and what it does not cover is critical to planning your health care budget and deciding whether you need additional private insurance. In this article, we will take a detailed look at which types of treatment are covered by AHCIP in full, which are covered in part, and which are not covered at all. We will also discuss why some services are not covered and what options you have for obtaining coverage for uncovered services.
The basic principle of AHCIP coverage: Medical necessity
Before we begin to look at specific types of treatment, it is important to understand the basic principle that determines whether AHCIP covers a particular medical service. This principle is called medical necessity. AHCIP only covers medical services that are considered medically necessary.
Medical necessity is determined by your doctor. If your doctor believes that a particular procedure, test, or treatment is medically necessary to diagnose, treat, or prevent a disease or injury, then those services will be covered by AHCIP. However, if a procedure or treatment is considered cosmetic, elective, or medically non-essential, it will not be covered.
This means that even if a certain procedure could improve your quality of life or make you happier, if it is not medically necessary, you will have to pay for it yourself or through private insurance. For example, cosmetic surgery, such as a facelift or lip augmentation, is not covered by AHCIP because it is not medically necessary. However, if the same procedure is performed for medical reasons, such as facial reconstruction after an injury or burn, it may be covered.
Services fully covered by AHCIP
Now let's take a closer look at what types of treatment and medical services are fully covered by AHCIP. These services cost you nothing at the time of service if you have a valid AHCIP card.
Doctor visits
All doctor visits that are medically necessary are fully covered by AHCIP. This includes consultations with your family doctor, visits to the emergency room, consultations with a specialist, and telemedicine. You do not pay any fees for consultations, tests, or referrals to specialists. This is one of the biggest advantages of the AHCIP system.
When you visit your family doctor for a routine check-up, diagnosis of symptoms, or prescription, you simply show your AHCIP card, and the doctor bills the provincial government directly. The same applies to visits to specialists such as cardiologists, endocrinologists, or gastroenterologists. However, it is important to note that you will need a referral from your family doctor to see most specialists.
Hospitalization and inpatient care
AHCIP fully covers all medically necessary hospitalizations and inpatient care. This includes your stay in the hospital, operating room, intensive care unit, food, and all medications you are given in the hospital. You do not pay for your hospital bed, food, treatment, or medication while you are in the hospital.
However, it is important to note that AHCIP only covers standard hospital rooms. If you want a private or semi-private room, you will have to pay an additional fee, unless the private room is medically necessary. The medical necessity of a private room is determined by a doctor and usually applies to cases where the patient has an infectious disease that could spread to other patients, or when the patient requires special care.
Surgical Procedures
All surgical procedures that are medically necessary are fully covered by AHCIP. This includes both emergency and elective surgeries. You do not have to pay for the surgery itself, the operating room, anesthesia, or post-operative rehabilitation if it is performed in a hospital.
AHCIP also covers some specialized surgical procedures, such as bariatric surgery for people who meet the criteria of the Weight Wise program, and gender confirmation surgery for people approved under the Gender Reaffirming Surgery Program in Alberta.
Diagnostic services
AHCIP fully covers all medically necessary diagnostic services. This includes X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, laboratory tests, and blood tests. All of these services are free if they are performed in a hospital or recommended by a doctor as medically necessary.
However, it is important to note that if you choose to have a diagnostic test done at a private clinic rather than at a hospital or provincially funded clinic, you will have to pay for the test yourself. For example, if you want to have an MRI done at a private clinic to avoid a long wait in the public system, you will have to pay for the MRI yourself.
Emergency Care
All visits to a hospital emergency department are fully covered by AHCIP. If you have a medical emergency, such as a heart attack, stroke, serious injury, or other life-threatening situation, you can go to the emergency department of any hospital in Alberta and you will not have to pay for treatment.
Childbirth and newborn care
AHCIP covers all medically necessary services related to pregnancy and childbirth. This includes prenatal visits to the doctor, ultrasounds ordered by your doctor, hospital delivery, cesarean section, and postpartum care in the hospital. If you give birth in a hospital, you will not have to pay for the care you receive during or after childbirth.
However, there are some pregnancy-related services that are not covered by AHCIP. These include private rooms in the hospital (unless medically necessary), doula services, and elective 3D ultrasounds that are not ordered by a doctor.
Psychiatric Care
AHCIP covers consultations with a psychiatrist. A psychiatrist is a doctor who specializes in diagnosing and treating mental illness. Psychiatrists can prescribe medication and provide medical care to treat conditions such as depression, anxiety, bipolar disorder, schizophrenia, and other mental illnesses.
However, it is important to understand the difference between a psychiatrist and a psychologist. A psychiatrist is a doctor with a medical degree who can prescribe medication. A psychologist is a mental health professional with a doctorate in psychology, but they are not a doctor and cannot prescribe medication. AHCIP covers visits to a psychiatrist, but does not cover visits to a psychologist, counselor, or psychotherapist.
Immunization and Screening Programs
AHCIP covers many immunizations and public health screening programs. This includes flu shots, COVID-19 vaccines, tuberculosis tests, cancer screening programs (mammograms, PAP tests), and other preventive services.
Services that are partially covered by AHCIP
There are several types of medical services that AHCIP only partially covers. This means that AHCIP pays part of the cost of the service, but you or your private insurer will have to pay the difference.
Eye care services (eye exams)
AHCIP partially covers eye care services, but coverage depends on your age. Children under the age of 18 and adults aged 65 and older are eligible for one complete eye exam per year at no cost. For adults aged 19 to 64, eye care services are not covered by AHCIP unless they are medically necessary due to an eye disease or injury.
If your eye exam costs more than the amount covered by AHCIP, your eye doctor may charge you an additional fee. Providers are required to discuss costs with patients before providing services.
Podiatric Services (Foot Care)
AHCIP provides partial coverage for some podiatric services under the basic podiatry program up to a maximum of $250 per year (July 1 to June 30). Podiatrists may charge you an additional fee for these services beyond what AHCIP covers.
Albertans are also eligible for full coverage for services provided by a pediatric surgeon at an Alberta hospital or at a non-hospital surgical facility that has a contract with Alberta Health Services. A referral from a physician is required to access the services of pediatric surgeons who have a contract with Alberta Health Services.
Dental and Maxillofacial Surgery
AHCIP provides partial coverage for some specialized dental, oral, and maxillofacial surgical services. This includes jaw fracture surgery, oral cancer surgery, and emergency trauma requiring surgery.
However, routine dental care such as teeth cleaning, fillings, crowns, bridges, dentures, and braces are not covered by AHCIP.
Services Not Covered by AHCIP
Now let's look at the types of treatment and medical services that are not covered by AHCIP at all. You will have to pay for these services yourself or through private insurance.
Prescription Drugs Outside the Hospital
One of the biggest gaps in AHCIP coverage is that the program does not cover prescription drugs obtained outside of a hospital. If you need regular medication to treat a chronic condition such as high blood pressure, diabetes, asthma, or depression, you will have to pay for these medications yourself.
However, Alberta has several additional programs that can help with the cost of medication. These include the Coverage for Seniors Program for people aged 65 and older and the Non-Group Coverage Plan for individuals without employer-sponsored insurance. These programs reduce the cost of chronic medications, but AHCIP itself does not cover prescription drugs.
General Dental Care
General dental care is not covered by AHCIP. This includes cleanings, fillings, crowns, bridges, dentures, braces, teeth whitening, and wisdom tooth removal (unless performed in a hospital as part of a more complex procedure). If you have dental health issues, you will need to purchase private dental insurance or pay for services out of pocket.
For low-income individuals or seniors, there are some assistance programs, such as the Dental and Optical Assistance for Seniors Program, that can help with the cost of dental care.
Eyeglasses and Contact Lenses
AHCIP does not cover the cost of eyeglasses, contact lenses, or laser eye surgery. If you need new eyeglasses or contact lenses, you will have to pay for them yourself or through private insurance.
Hearing Aids
Hearing aids are not covered by AHCIP. If you need a hearing aid, it can be very expensive, and you will need to purchase private insurance or pay for it yourself. However, there is a program called Alberta Aids to Daily Living that may provide some assistance for hearing aids for people who meet certain criteria.
Physical therapy
In general, physical therapy is not covered by AHCIP. However, there are some exceptions. If you need physical therapy due to a broken bone or complications after surgery (especially orthopedic surgery such as hip or knee replacement), physical therapy may be covered by Alberta Health Services.
As of March 2022, Alberta Health Services has expanded its coverage of physiotherapy for people who have fractures or have recently had orthopedic surgery. You can book an appointment at a clinic in the AHS directory if the fracture or surgery occurred within the last 12 weeks. No referral is required.
However, if you need physical therapy for a strain, tendonitis, or sprain, it will likely not be covered by AHCIP, and you will have to pay through private insurance or out of pocket.
Chiropractic, Massage Therapy, and Acupuncture
AHCIP does not cover services from chiropractors, massage therapists, acupuncturists, homeopaths, nutritionists, or other alternative medical practitioners. If you want these services, you will need to pay for them yourself or through private insurance.
Many employers offer extended health insurance plans that cover some of these services up to a certain limit per year. For example, your plan may cover up to $500 per year for chiropractic care or up to $300 per year for massage therapy.
Mental Health Counseling and Therapy
As we mentioned earlier, AHCIP covers visits to a psychiatrist, but it does not cover visits to a psychologist, counselor, psychotherapist, or social worker. If you need mental health counseling or therapy, you will have to pay for these services yourself or through private insurance.
However, there are some low-cost or free counseling programs available through community organizations, religious groups, or Alberta Health Services mental health services for people in crisis.
Ambulance Services
One of the most unexpected gaps in AHCIP coverage is that ambulance services are not fully covered. If you need an ambulance to transport you to a hospital or between hospitals, AHCIP may cover part of the cost, but you may be left with a significant bill.
The typical cost of a ground ambulance in Alberta is between $250 and $385. Air ambulance costs $600 or more. Exceptions are seniors (partially covered) and medical transportation between hospitals, which is fully covered.
Cosmetic Surgery
Cosmetic surgery is not covered by AHCIP unless it is deemed medically necessary by a doctor. Examples of non-covered cosmetic procedures include facelifts, lip augmentation, Botox, liposuction, vasectomy reversal, abdominoplasty (tummy tuck, unless medically necessary), and most breast reduction procedures (mammoplasty).
However, if a cosmetic procedure is deemed medically necessary by a doctor, it may be covered. For example, panniculectomy (tummy tuck to remove excess skin after massive weight loss) may be covered if the excess skin causes medical problems such as infections or mobility issues.
Travel Vaccines
Vaccines required for travel to other countries are not covered by AHCIP. If you plan to travel to a country that requires special vaccines, such as yellow fever, hepatitis A, or malaria, you will have to pay for these vaccines yourself.
Prosthetics, walkers, and other assistive devices
AHCIP does not cover the cost of medical and surgical devices, prosthetics, mobility aids, wheelchairs, and other assistive devices. However, there is an Alberta Aids to Daily Living program that may provide some assistance for these items for people who meet certain criteria.
Coverage outside Alberta
If you travel to another province in Canada, your AHCIP card will be accepted at most hospitals and doctors' offices. Alberta has reciprocal agreements with all provinces and territories for insured hospital services. You can receive insured medical services at any publicly funded or general hospital in Canada.
However, it is important to know that you will only be reimbursed for services that would be covered by AHCIP in Alberta. If a service is not covered by AHCIP in Alberta, it will not be covered outside of Alberta.
If you choose to receive treatment at a private facility in another province or territory, you are responsible for paying the cost of medical services in excess of the amount covered by AHCIP. You are also responsible for paying facility fees, including laboratory services, MRIs, and accommodation.
Coverage outside Canada
AHCIP only covers limited medical and hospital expenses outside Canada. If you receive medical or hospital care outside Canada, you will be responsible for paying the difference between the amount charged and the amount that AHCIP will reimburse you.
If you claim coverage under AHCIP, you will still have to pay the healthcare provider. You can then submit a claim to the AHCIP office for reimbursement of eligible healthcare expenses incurred outside the country. Reimbursement is issued in Canadian dollars only.
It is strongly recommended that you have additional travel medical insurance when traveling outside of Alberta or Canada.
Additional Coverage Programs in Alberta
In addition to AHCIP, Alberta offers several additional coverage programs that can help with expenses not covered by AHCIP.
Coverage for Seniors Program
This program provides additional coverage for Alberta residents aged 65 and older. It helps cover the cost of prescription drugs, certain dental services, optical services, and ambulance subsidies.
Non-Group Coverage Plan
This program is for individuals who do not have employer-sponsored insurance. It helps cover the cost of prescription drugs, hospital accommodation, and diabetic devices.
Alberta Child Health Benefit
This program provides assistance to low-income families to cover the cost of their children's health care.
Dental and Optical Assistance for Seniors Program
Seniors with low or moderate incomes may be eligible for certain benefits under the Dental and Optical Assistance for Seniors Program.
Why Private Insurance is Important
Given all the gaps in AHCIP coverage, many Albertans choose to purchase private health insurance to cover services not covered by AHCIP. Private insurance can cover prescription drugs, dental care, optical services, physiotherapy, chiropractic care, massage therapy, psychological counseling, and many other services.
Many employers offer group health insurance as part of their employee benefits package. If you have access to insurance through your employer, this is usually the cheapest way to get extended coverage. If you do not have insurance through your employer, you can purchase individual or family health insurance from private insurance companies.
The cost of private insurance can vary widely depending on the level of coverage you choose, but it typically ranges from $50 to $300 per month for an individual or $100 to $600 per month for a family.
Conclusion: AHCIP is a solid foundation, but it doesn't cover everything
The Alberta Health Care Insurance Plan provides a solid foundation of health coverage for residents of Edmonton and the entire province of Alberta. The program covers all medically necessary doctor and hospital services, including doctor visits, hospitalization, surgical procedures, diagnostic tests, and emergency care. This gives you peace of mind knowing that if you have a serious medical problem, you will receive the necessary treatment without huge bills.
However, it is important to understand that AHCIP does not cover all types of treatment and medical services. The program does not cover prescription drugs outside of the hospital, dental care, optical services, hearing aids, physical therapy, chiropractic care, psychological counseling, and many other services. For these services, you will either need to pay out of pocket or purchase private health insurance.
Understanding what AHCIP does and does not cover will help you better plan your healthcare expenses and make informed decisions about whether you need additional private insurance. If you have chronic conditions that require regular medication, or if you want access to services such as dental care or physical therapy, it is highly recommended that you purchase additional private insurance.
Finally, if you plan to travel outside of Canada, be sure to purchase travel medical insurance, as AHCIP coverage outside of Canada is very limited.