What services are covered by public health insurance?

Public health insurance in Calgary is provided through the Alberta Health Care Insurance Plan (AHCIP), which provides residents of the province with access to a wide range of health services. This system is the foundation of healthcare in Alberta and covers most necessary medical services for individuals who meet the program's eligibility criteria. Let's take a closer look at which services are covered and which are not covered by public insurance.

Overview of the AHCIP

The Alberta Health Care Insurance Plan (AHCIP) is a publicly funded health care system that provides residents of Calgary and the entire province of Alberta with access to medically necessary services. To be eligible for coverage, you must be registered in the program and have a valid Alberta Health Services card. The system covers approximately 71% of total health care costs, with the remaining 29% funded by private sources.

Eligibility criteria for AHCIP

To be eligible for AHCIP coverage, an individual must meet the following criteria:

  • Be legally authorized to be in Canada and have a permanent residence in Alberta
  • Be physically present in Alberta for at least 183 days during any 12-month period
  • Not be applying for residency or benefits in another province, territory, or country

Fully covered services

Physician and specialist services

AHCIP fully covers all medically necessary services provided by physicians and specialists. This includes:

  • Family doctor consultations
  • Specialist consultations by referral
  • Psychiatric consultations
  • Medical examinations, if medically necessary
  • Diagnostic procedures ordered by a doctor

Hospital services

Public insurance covers a wide range of services related to hospital stays:

  • Standard room and board
  • Nursing services
  • Laboratory tests and X-rays
  • Use of operating, radiotherapy, and anesthesiology facilities
  • Routine surgical equipment and supplies
  • Interfacility transportation within Alberta by ambulance

Surgical procedures

AHCIP covers medically necessary surgical procedures, including:

  • General surgical procedures
  • Bariatric surgery for obese patients who meet the Wise Weight program criteria
  • Sex reassignment surgery, including breast augmentation and mastectomy for transgender individuals
  • Vasectomy
  • Maxillofacial surgery

Partially covered services

Dental services

AHCIP provides partial coverage for certain dental services:

  • Specific dental, oral, and
  • For low- and moderate-income seniors, the Senior Dental and Vision Assistance Program is available (limited to $5,000 every five years for eligible procedures)

However, routine dental services such as cleanings, fillings, and wisdom tooth extractions are not covered.

Ophthalmological services

Coverage for ophthalmological services depends on the patient's age:

  • Full coverage for children under 18 and adults over 65
  • Limited coverage for adults aged 19-64 (only if services are medically necessary)

Effective February 1, 2025, changes were made to the coverage of ophthalmic services, and some services, such as partial vision screening, retinal imaging, and retinal photography, may no longer be covered by the plan.

Podiatry services

AHCIP provides partial coverage for podiatry (foot care) services. These services have benefit limits or annual benefit maximums and are only covered within Alberta.

Services for special populations

Coverage for children

Children in Alberta have access to extended coverage through the Alberta Child Health Benefit:

  • The program covers medical services such as eyeglasses, prescription drugs, and dental care that are not available through standard AHCIP coverage
  • Families with limited income (up to $24,397 per year for a family with one child) are eligible to participate
  • The program covers children up to age 20 who live at home and are enrolled in school up to grade 12

Coverage for seniors

The Alberta government provides seniors with free coverage for prescription drugs and other medical services not included in AHCIP through the Coverage for Seniors Program:

  • The program is automatically added to your AHCIP account on the first day of the month after your 65th birthday
  • Coverage includes prescription drugs, some dental and vision services
  • The program does not include travel insurance, so it is recommended that you purchase additional insurance for travel outside the province or country

Coverage for pregnant women

Public health insurance provides comprehensive coverage for pregnant women:

  • Visits to a doctor and obstetrician-gynecologist
  • Childbirth and postpartum care
  • Hospital stays
  • Ultrasound and other laboratory tests
  • Pregnancy-related surgical procedures
  • Emergency services
  • Newborn care

Services not covered by AHCIP

Alternative medicine and additional services

AHCIP does not cover the following services:

  • Complementary or alternative medical treatments, such as chiropractic, massage, naturopathic, dietitian, or social worker services
  • Psychological services (although psychiatric consultations are covered)
  • Physical therapy in private clinics (although some physical therapy services may be covered in hospitals)

Medications and medical equipment

The following services and items are not covered by AHCIP:

  • Prescription drugs, except those prescribed during a hospital stay
  • Eyeglasses, contact lenses, or laser vision correction
  • Medical devices or mobility aids, such as wheelchairs
  • Hearing aids

Cosmetic procedures and non-essential services

AHCIP does not cover:

  • Cosmetic surgery (e.g., tummy tucks) unless medically necessary
  • Medical certificates and form completion
  • Travel vaccinations and certain immunizations

Emergency services

Emergency services are not covered by AHCIP, except for transfers from one medical facility to another. Patients must pay for these services themselves or through private insurance.

Coverage for services outside the province

Coverage within Canada

AHCIP provides coverage for insured medical and hospital services in other provinces of Canada:

  • In most cases, if you present a valid Alberta health care card to a medical or hospital provider outside the province and receive insured services, it will not cost you anything
  • If AHCIP does not cover a service in Alberta, it will not be covered outside Alberta
  • Alberta has reciprocal agreements with all provinces and territories except Quebec for insured drug services

Restrictions on elective procedures

If you decide to receive scheduled (non-emergency) medical services in another province or territory, coverage may be limited:

  • Before booking any scheduled medical services outside Alberta, it is recommended that you contact the Out-of-Province Services Department
  • AHCIP does not cover food, transportation, lodging, or other expenses related to receiving medical services outside of Alberta

Additional programs and coverage

Drug coverage program

For individuals who need assistance with the cost of prescription drugs, the following programs are available:

  • Alberta covers drugs administered in hospitals
  • Low-income seniors may be eligible for financial assistance to help cover monthly living expenses
  • Albertans who are eligible for non-group coverage (under age 65) pay 30% of the cost of prescription drugs, up to a maximum of $25

Mental health programs

Although AHCIP does not cover counseling services, there are other options for mental health assistance:

  • A publicly funded mental health support system run by Recovery Alberta (formerly Alberta Health Services) offers a wide range of treatments for issues such as depression, anxiety, and addiction
  • If an individual is being treated for mental health issues through a medical or hospital visit, treatment is covered
  • Some family doctors (general practitioners) are trained and licensed to provide psychotherapy, in which case it is covered by public insurance

Conclusion

Public health insurance in Calgary through the Alberta Health Care Insurance Plan (AHCIP) provides residents with access to a wide range of medical services. It covers most medically necessary services, including doctor visits, hospital care, and surgical procedures. However, there are limitations on coverage, particularly for dental, vision, prescription drugs, and alternative medicine.

To maximize the benefits of public health insurance, it is important to understand which services are covered and which require additional private insurance. Special populations, such as children, seniors, and pregnant women, may have access to additional programs that expand the standard AHCIP coverage.

Despite its limitations, Calgary's public health insurance system provides access to quality healthcare for all residents who meet the program criteria, regardless of their financial situation.