alberta aids to daily living primary module b, part 1 ...€¦ · general policies and procedures...

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Alberta Aids to Daily Living (AADL) Primary Module B

General Policies and ProceduresPart 1

AADL General Policies and Procedures

Overview

Alberta Aids to Daily Living (AADL) Overview

Purpose:

• To provide an overview of the AADL program

• To provide information on the various AADL stakeholders, benefits, forms, processes and resources

Alberta Health - Pharmaceutical and Supplementary Benefits Alberta Aids to Daily Living Module B, Part 1 - General Policies and Procedures

© 2019 Government of Alberta Revised March 2019

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What is Alberta Aids to Daily Living?

The AADL program helps Albertans with long-term disability, chronic illness or terminal illness to maintain their independence in their residence and community by providing financial assistance to purchase medical equipment and supplies.


• All residents of Alberta with valid Alberta Health Care coverage are eligible

• AADL is a cost-sharing program

• Benefit year is from July 1 to June 30


Stakeholders



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Stakeholders

There are three mainstakeholders involved in the AADL program.

Clients and their

representatives

Authorizers and

Specialty Assessors

Vendors and Specialty Suppliers

Stakeholders

Authorizer

• A health care professional who assesses a client's medical needs and eligibility for AADL benefits.

Vendor

• A business with an agreement with AADL to provide medical equipment and/or supplies to AADL clients.

Stakeholders

Specialty Assessor• A health care professional that is employed by a

Specialty Supplier.• Assess a client’s medical needs and eligibility for

AADL benefits

Specialty Supplier• A business with an agreement with AADL to provide

medical equipment and/or supplies to AADL clients.• Employs Specialty Assessors



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Stakeholders

Authorizer/Vendor

Client assessed by Authorizer

Client selects Vendor

Vendor provides benefit to Client

Vendor invoices AADL and Client

Specialty Supplier

Client selects Specialty Supplier

Client is assessed by a Specialty Assessor

Specialty Supplier provides benefit to Client

Specialty Supplier invoices AADL and Client


General Eligibility Criteria


Permanent resident of

Alberta

Valid Alberta Personal Health Number (PHN)

Authorization completed by an

Authorizer or Specialty Supplier

Sign the client declaration form

Authorization validated by

AADL



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Home Living

Independent Living

Eligible for all AADL benefits

Assisted/Supportive Living (1&2)

Seniors lodges, retirement

communities, personal care homes

Eligible for all AADL benefits


Supportive Living levels 3 & 4

SL3, SL4 and SL4D

- Eligible for ostomy and incontinence supplies, walkers,

wheelchairs & compression garments

- Not eligible for bathing/toileting aids, beds, overlays, bed rails, lifters or

transfer pole aids

Long Term Care

Includes nursing homes, auxiliary and extended care

- Eligible for walkers, wheelchairs, compression

garments

- Not eligible for bathing/toileting aids, beds, overlays, bed rails,

lifters, transfer pole aids, ostomy or incontinence supplies.


Benefit Overview



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Benefit Overview

• Primary product ranges assigned based on discipline– Included as part of today’s training

• Secondary product ranges requires separate application– Require specialized clinical skills

– Must already be an AADL Authorizer

– Criteria is listed in benefit specific manuals

Benefit OverviewPrimary Product Ranges

Occupational Therapists and Physiotherapists– Pediatric equipment

– Soft Supports

– Bathing and Toileting equipment (small)

– Walking aids

– Bathing and Toileting equipment (large)

– Transfer Aids and Overlays

– Homecare Beds and Lifters

Benefit OverviewPrimary Product Ranges

Registered Nurses– Ostomy

– Incontinence

– Catheters

– Soft supports

– Bathing & toileting equipment (small)

– Homecare beds and lifters

– Transfer aids and overlays



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Benefit OverviewSecondary Product Ranges

• Burn garments – OT, PT, RN

• Compression garments – OT, PT, RN

• Incontinence supplies – OT, PT

• Seating – OT, PT

• Speech generating communication devices –SLP, OT

• Wheelchairs – Manual and Power – OTs and PTs

Benefit Overview

Mobility & large equipment

Medical and surgical benefits

Hearing and augmentative

communication

Prosthetics, orthotics,

seating and footwear

Respiratory

Benefit Overview

Mobility and Large Equipment

Manual and Power

wheelchairs

Bathing and Toileting Aids

Wheelchair Accessories

Pediatric equipment

Patient lifters Walking AidsHomecare beds



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Benefit Overview

Medical and Surgical

Incontinence supplies

Ostomy Supplies

Compression garments

Soft supports

Burn garments

Breast prostheses &

Syringes

Benefit Overview

Hearing and Augmentative Communication

Hearing AidsAugmentative

speech & communication

Laryngectomy supplies

Benefit Overview

Prosthetics, Orthotics, Seating and Footwear

Prosthetics

Seating

Orthotics

Footwear



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Benefit Overview

Respiratory

Oxygen VentilatorsBPAP

Tracheostomy tubes

Suction & humidity therapy

Resuscitator & bagging

units

Benefit Overview

• Each benefit area has Policies and Procedures, and Approved Product Lists (APLs) .

• Only benefits listed on the Approved Product Lists are funded by AADL.

• Benefits have a maximum quantity, frequency, and price.

• Each benefit area have benefit clerks and a program manager.


Authorizer Roles and Responsibilities



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Advocate

Role

Authorizer

Role


As an authorizer, you are accountable for the authorizations submitted to AADL and must:

1. Comply with AADL policies and procedures

2. Confirm client’s meet all eligibility criteria prior to authorizing benefits

3. Ensure the authorization form is accurate and complete

4. Advise AADL when you change facilities, name or no longer require authorizer status


Authorizers must not:

1. Profit from the sale or supply of benefits to clients

2. Discriminate or intentionally malign a vendor

3. Authorize benefits for themselves, family or friends



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Forms and Processes

Forms and Processes

Most commonly used forms for authorizing:

• General Authorization form (1250)

• Authorization form for wheelchairs (1251)

• Correction and Change form

• Cost-Share Exemption

• Temporary Cost-Share Exemption

• Quantity and Frequency Review (QFR) Request

Forms and Processes

Go to Datagroup.com and registerto obtain Authorization forms, Correction and Change forms, Brochures and AADL return envelopes.



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Forms and Processes

Authorization form (1250)

• Used for all benefits except wheelchairs

• Documents the assessment and authorize benefits

Forms and Processes

Wheelchair Authorization form (1251)

• Only used for manual and power wheelchairs

Forms and Processes

Authorization Correction and Change form

• Used for adding, deleting, changing benefits or extending authorizations



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Forms and Processes

Some benefits require additional documentation. These may include (but are not limited to):

• Wheelchair Adult-Tilt-in-Space Request form

• Manual Wheelchair Specification forms

• Assessment Summary for Incontinence Products

• Lower Leg Assessment Form

• Assessment Summary for Bathlift Benefit

Refer to the benefit manual to determine if additional forms are required.

Forms and Processes

Cost-Share • Clients are required to pay 25% of the approved

benefit amount up to a maximum of $500 per family per benefit year

• Benefit year is July 1 – June 30

• Respiratory is cost share exempt

• Prosthetics, Orthotics, Breast Prostheses and Ocular are cost share exempt for clients over 65 and their dependents

Forms and Processes

There are several ways a client can qualify for Cost-Share Exemption:

• Cost-Share Exemption

• Temporary Cost-Share Exemption

• Cost-share Appeal

• Hearing Aid Benefit Cost-Share Exemption

• Reached the yearly $500 maximum

• AISH

• Income Support Program

• Alberta Adult Health Benefits



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Forms and Processes

Cost-Share Exemption• Explain cost-share policy to

client

• Provide client with cost-share exemption form– $20,970 or less for single coverage

– $33,240 or less for a family with no children

– $39,250 or less for a family with children

Forms and Processes

Temporary Cost-Share Exemption• Have experienced

significant income reduction for at least three months

• If client has not filed income tax return in past year

Forms and Processes

Complaints• AADL has a formal complaint process

• Submitted by:– Complaint form

– Letter

– Telephone

• Anyone can submit a complaint

• Cannot be anonymous



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Quantity and Frequency Review Process

Quantity and Frequency Review

Quantity and Frequency Review (QFR) Requests are submitted when a client’s clinical needs have changed


All Quantity and Frequency (QFR) requests require the following:

• An assessment identifying clinical need

• Rationale explaining why the existing benefit no longer meets the client’s clinical needs

• General and benefit specific eligibility criteria must be met



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Request meets QFR criteria

Advise the client of the QFR

process

Complete and fax the QFR form and supporting documentation


QFR Approved

Complete authorization

form

QFR Denied

May appeal to QFR Appeal

Committee


Submit QFR Appeal to the

Director

If approved, submit

authorization

If denied, pursue

alternate funding

QFR Appeal to the Director Process



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AADL Resources

Interactive Voice Response

The Interactive Voice Response (IVR) is an automated telephone system that allows authorizers to check:

• Client’s cost-share status

• Benefits the client has received

• Status of an authorization

Interactive Voice Response

How to enter letters

Authorizer number NR123

N = 62

R = 73

62 73 123



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Brochures

General Brochure

• AADL benefits

• Client eligibility requirements

• Where to get equipment and supplies

• How to access AADL benefits

• Cost-share and how to apply for Cost-Share Exemption

• Contact Information

Website

• https://www.alberta.ca/alberta-aids-to-daily-living.aspx

• Policy and Procedures

• Program Manuals

• Vendor Lists

• Forms

• Bulletins

• Contact list for AADL staff

AADL has an e-mail subscription to receive notices of updates to the AADL website.

Questions?



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Alberta Aids to Daily Living Program10th Floor, Milner Building10040 104 StreetEdmonton, Alberta T5J 0Z2

TelephoneEdmonton and area: 780-427-0731Toll-free in Alberta: 310-0000, then 780-427-0731

Deaf/hearing impaired callers within Alberta using a TTY can reach the provincial government by dialing 780-427-9999 in Edmonton or 1-800-232-7215 throughout Alberta.

Fax: 780-422-0968

https://www.alberta.ca/alberta-aids-to-daily-living.aspx

© 2019 Government of Alberta

