Dental and Optical Assistance for Seniors

Frequency limitations

Based on the Dental Assistance for Seniors Program Fee Schedule, frequency limitations may apply for specific dental services.

Dental providers may choose to perform dental services more frequently than permitted under the program. 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.

Optical assistance

Optical Assistance for Seniors Program provides financial assistance for the purchase of prescription eyeglasses up to a maximum of $230 every 3 years, depending on your eligibility at the time of purchase.

When you first enroll into the program, the 3-year period of coverage will begin on the date that you receive the first funded optical service under this program.

If you do not use the maximum benefit within the 3-year period, the remaining amount will not carry over into the next.

Basic optical services covered under this program include:

• prescription eyeglasses
• prescription sunglasses
• prescription lenses (including contact lenses)
• frames
• eyeglass repairs

Optical services not covered include:

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

* Eye exams are a partially covered service under the Alberta Health Care Insurance Plan (AHCIP). For more information, read about health care services covered in Alberta.

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.

Read Cataract surgery claims below for more information.

How to submit a 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. Contact information is provided below.

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 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

Direct billing available

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 the program.

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

Direct billing not available

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

Dental

You may collect a reimbursement claim form from your dental provider or the Alberta Dental Service Corporation(ADSC). Ensure the claim form is complete and includes your personal health number.

You can also submit the dental claim online directly to ADSC. Create an ADSC account. Your online account will track your remaining dental funding, if a previous claim has been paid, and allow you to update your address or banking information.

Optical

You may collect a reimbursement claim form from your optical provider or Alberta Blue Cross (ABC). Ensure the claim form is complete and includes your personal health number. Submit to the address included on the form.

If you create an ABC online account, you will be able to track if your claim has been paid.

All dental and optical claims must be submitted within 12 months of an expense being incurred. If you do not submit the claim within 12 months, reimbursement will not be provided.

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 may be 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

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

Program 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 Centre
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 fee 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

If your questions were not resolved after calling the Alberta Dental Services Corporation, you or your dental provider can request a review of your dental claim by writing to:

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

Dental claim exceptions

Your dental provider may submit an exception review on your behalf if the Alberta Dental Services Corporation did not approve a dental service.

All requests are reviewed by the Alberta Dental Service Corporation Review Committee. The exception review request must include:

• the dental treatment plan
• clinical and medical rationale and diagnostic information that supports your exception review request

Note: Dental services not listed in the dental fee schedule that are provided to a senior before the request is reviewed by the Alberta Dental Services Corporation Review Committee will not be funded.

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.

Your dental provider will receive a written response from the Alberta Dental Service Corporation Review Committee once a decision has been reached. If you have questions regarding the outcome of a dental exception, contact your dental provider or:

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

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.