Dental and Optical Assistance for Seniors

Frequency limitations

As per the fee schedule, frequency limitations may apply for specific dental services.

Dental providers may choose to perform dental services more frequently than permitted under the fee schedule. The senior is responsible for the cost of these services if they choose to proceed.

Out-of-province or out-of-country claims

All dental services and procedures supported by this program must be completed by a dental provider located within Alberta. Any dental services and procedures completed outside of the province or outside of the country will not be reimbursed.

Optical coverage

Eligible seniors are provided up to a maximum of $230 for select optical services every 3 years. When you are first enrolled into the program, the 3-year period begins on the date that you first use optical service funding.

Every 3 years, your $230 of funding is renewed. If you do not use the full $230 in this time period, the remaining amount will NOT carry over into the next 3-year period.

Services covered

Prescription eyeglasses, including lenses and frames purchased from a regulated optical provider in Alberta, are eligible for coverage. The maximum funding amount is based on your eligibility at the time of purchase.

Optical services not covered include:

• eye surgery
• lenses for cataract surgery
• eye exams
• accessories
• magnifying devices
• eye medication
• non-prescription sunglasses

Frequency limitation

If you purchase prescription eyeglasses within the 3-year period and you do not use your full optical benefit at that time, you can use the remaining funds before the 3-year period ends.

Cataract surgery

Assistance with an additional set of eyeglasses within the same 3-year period may be provided to an eligible senior when they had cataract surgery that led to a change in prescription.

Refer to Cataract Surgery Claims below for more information.

Submit dental or optical claim

Alberta Health has contracted the Alberta Dental Service Corporation to be the benefit administrator for all dental claims and to provide you with information about the Dental Assistance for Seniors program and answer questions regarding dental claims and payment.

Alberta Health has contracted Alberta Blue Cross to be the benefit administrator for optical claims and to provide you with information about the Optical Assistance for Seniors program and answer questions regarding optical claims and payment.

Contact information for the Alberta Dental Services Corporation and Alberta Blue Cross is provided below.

Step 1: Talk to your health service provider when visiting

When visiting a dental or optical office, present your Alberta health card and tell the service provider that you are a senior and enrolled in the Dental and Optical Assistance for Seniors programs.

The service provider can confirm your eligibility and coverage rate at the time of your appointment by submitting a pre-authorization to the benefit administrator.

Step 2: Payment for services

Note: If direct billing is available, you will only pay the amount not covered by your plan.

Dental or optical offices may bill the benefit administrator directly for services provided to you. If your service provider accepts this method, you will only be required to pay any outstanding amount not covered by your plan.

If your dental or optical provider submits a claim directly to the benefit administrators, skip Step 3.

Note: If direct billing is not available, you will have to pay the full amount and submit a claim for reimbursement.

Dental or optical offices may not bill the benefit administrator directly for services provided to you. If this occurs, you will be required to pay the full balance and submit your receipts for reimbursement. You or your service provider must also complete sections of a reimbursement form.

If your dental or optical provider does not submit claims directly to the benefit administrators, go to Step 3 below.

Step 3: Submit a reimbursement claim

Reimbursement Claim Forms are available from:

• Alberta Dental Service Corporation (Dental Assistance for Seniors)
• Alberta Blue Cross (Optical Assistance for Seniors)
• your dental and optical service provider

Ensure the claim form is complete and includes your personal health number.

All dental and optical claims must be submitted within 12 months of an expense being incurred. Reimbursement will not be provided after this time.

Complete the reimbursement claim form and mail to the address on the form or:

• Dental – Submit the claim directly to the Alberta Dental Services Corporation by creating an online account with them. Your account will also inform you of your remaining balance, tell you if a previous claim has been paid, and allow you to update your address or banking information.
• Optical – Submit the claim directly to Alberta Blue Cross by creating an online account with them. Your account will also inform you if your claim has been paid.

Cataract surgery claims

If you had cataract surgery after receiving funding within the same 3-year period and there is a change in your prescription, you are eligible for additional funding. To be eligible for this additional funding, you must have a medical note confirming the date of your cataract surgery.

Your optical provider can submit this claim, along with the medical note, on your behalf directly to Alberta Blue Cross. This process is based on the optical provider entering the confirmed date of cataract surgery and uploading documentation confirming your cataract surgery.

Reviews and exceptions

You can request a review if you were denied funding or funded less than expected for a dental or optical claim.

Income eligibility reviews and exceptions

To request an explanation of the income information used to determine your eligibility for the program, contact the Alberta Seniors Benefit program via:

Alberta Support Contact Center
Hours: 7:30 am to 8 pm (open Monday to Friday, closed statutory holidays)
Toll free: 1-877-644-9992

Dental claim reviews

If you have questions regarding the outcome of a dental claim, the amount paid by the program or why a dental service was not approved, contact:

Alberta Dental Service Corporation
Phone: 1-800-232-1997
Email: [email protected]
Fax: 780-426-7581

Dental claim exceptions

If your questions were not resolved after calling the Alberta Dental Services Corporation, or you are requesting exception coverage for a dental service that was not approved or is not an eligible benefit, your dental provider can request a review of your dental claim by writing to:

Alberta Dental Service Corporation
17010 103 Avenue NW
200 Quikcard Centre
Edmonton, Alberta T5S 1K7

Your dental provider may also submit an exception review on your behalf prior to treatment. All requests are reviewed by the Alberta Dental Service Corporation Review Committee.

• The request must include a dental treatment plan with medical rationale and diagnostic information that will support your exception request.

Each request is reviewed on an individual basis, taking into consideration the eligible dental options available, the medical necessity of the requested treatment, the overall oral condition of the mouth and all pre-existing medical conditions. The information submitted will be used to ensure the proposed dental exception is the most cost effective service and sustainable for a prolonged period.

Dental procedures that are not listed in the dental fee schedule and completed without pre-authorization will not be considered for exception review.

Optical claim reviews

If you have questions regarding the outcome of an optical claim, the amount paid by the program or why an optical service was not approved, contact:

Alberta Blue Cross
Phone: 1-800-661-6995

Optical claim exceptions

If your questions are not resolved after calling Alberta Blue Cross, or you are requesting exception coverage for an optical service that was not approved or is not an eligible benefit, you can request a review of your optical claim by writing to the Optical Assistance for Seniors program:

Optical Assistance for Seniors
PO Box 3100 Stn Main
Edmonton, Alberta  T5J 4W3

The program will review your written request and respond by letter.