CANADA HEALTH ACT ANNUAL REPORT 2014

CANADA HEALTH ACT ANNUAL REPORT 2014
Accessibility
CANADA HEALTH ACT
Public Administration
CANADA HEALTH ACT
Public Administration
Accessibility
Universality
Universality
Portability
ANNUAL REPORT 2014–2015
Comprehensiveness
Comprehensiveness
Portability
ANNUAL 2014
REPORT 2015
Health Canada is the federal department responsible for helping the people of Canada maintain
and improve their health. Health Canada is committed to improving the lives of all of Canada’s
people and to making this country’s population among the healthiest in the world as measured
by longevity, lifestyle and effective use of the public health care system.
Published by authority of the Minister of Health.
Canada Health Act – Annual Report 2014–2015
is available on Internet at the following address:
http://www.hc-sc.gc.ca/hcs-sss/pubs/cha-lcs/index-eng.php
Également disponible en français sous le titre:
Loi canadienne sur la santé – Rapport Annuel 2014-2015
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For further information or to obtain additional copies, please contact:
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© Her Majesty the Queen in Right of Canada, represented by the Minister of Health of Canada, 2015
All rights reserved. No part of this information (publication or product) may be reproduced or transmitted in any form or
by any means, electronic, mechanical, photocopying, recording or otherwise, or stored in a retrieval system, without prior
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HC Pub: 150140
Cat.: H1-4E-PDF
ISBN:1497-9144
ACKNOWLEDGEMENTS
Health Canada would like to acknowledge the work and effort that went into producing this Annual Report. It is through the
dedication and timely commitment of the following departments of health and their staff that we are able to bring you this report
on the administration and operation of the Canada Health Act:
Newfoundland and Labrador Department of Health and Community Services
Prince Edward Island Department of Health and Wellness
Nova Scotia Department of Health and Wellness
New Brunswick Department of Health
Quebec Ministry of Health and Social Services
Ontario Ministry of Health and Long-Term Care
Manitoba Health, Healthy Living and Seniors
Saskatchewan Health
Alberta Health
British Columbia Ministry of Health
Yukon Health and Social Services
Northwest Territories Department of Health and Social Services
Nunavut Department of Health
We also greatly appreciate the extensive work effort that was put into this report by our production team: the desktop publishing
company, the translators, editors and concordance experts, printers and staff of Health Canada at headquarters and in the
regional offices.
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TABLE OF CONTENTS
Acknowledgements___________________________________________________________________________________________ i
Introduction_________________________________________________________________________________________________1
Chapter 1 — Canada Health Act Overview_________________________________________________________________________3
Chapter 2 — Administration and Compliance______________________________________________________________________11
Chapter 3 — Provincial and Territorial Health Care Insurance Plans in 2013–2014________________________________________19
Newfoundland and Labrador________________________________________________________________________21
Prince Edward Island______________________________________________________________________________31
Nova Scotia______________________________________________________________________________________39
New Brunswick___________________________________________________________________________________49
Quebec_________________________________________________________________________________________ 59
Ontario_________________________________________________________________________________________63
Manitoba________________________________________________________________________________________75
Saskatchewan_____________________________________________________________________________________85
Alberta__________________________________________________________________________________________95
British Columbia_________________________________________________________________________________103
Yukon__________________________________________________________________________________________115
Northwest Territories____________________________________________________________________________ 125
Nunavut________________________________________________________________________________________133
Annex A — Canada Health Act and Extra-Billing and User Charges Information Regulations____________________________141
Annex B — Policy Interpretation Letters________________________________________________________________________163
Annex C — Dispute Avoidance and Resolution Process under the Canada Health Act___________________________________171
Contact Information for Provincial and Territorial Departments of Health__________________________________inside back cover
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INTRODUCTION
Canada has a predominantly publicly financed and administered health care system. The Canadian health insurance system
is achieved through 13 interlocking provincial and territorial
health insurance plans, and is designed to ensure that all
eligible residents of Canadian provinces and territories have
reasonable access to medically necessary hospital and physician
services on a prepaid basis, without charges related to the
provision of insured health services.
The Canadian health insurance system evolved into its present
form over more than six decades. Saskatchewan was the first
province to establish universal, public hospital insurance in
1947 and, ten years later, the Government of Canada passed
the Hospital Insurance and Diagnostic Services Act (1957), to
share in the cost of these services with the provinces and
territories. By 1961, all the provinces and territories had public
insurance plans that provided universal access to hospital
services. Saskatchewan again pioneered by providing insurance
for physician services, beginning in 1962. The Government of
Canada enacted the Medical Care Act in 1966 to cost-share the
provision of insured physician services with the provinces and
territories. By 1972, all provincial and territorial plans had been
extended to include physician services.
In 1979, at the request of the federal government, Justice
Emmett Hall undertook a review of the state of health services
in Canada. In his report, he affirmed that health care services
in Canada ranked among the best in the world, but warned that
extra-billing by doctors and user charges levied by hospitals
were creating a two-tiered system that threatened the universal
accessibility of care. This report, and the national debate it generated, led to the enactment of the Canada Health Act in 1984.
The Canada Health Act is Canada’s federal health insurance
legislation and defines the national principles that govern
the Canadian health insurance system, namely, public administration, comprehensiveness, universality, portability and
accessibility. These principles reflect the underlying Canadian
values of equity and solidarity.
The roles and responsibilities for Canada’s health care system
are shared between the federal, provincial and territorial
governments. The provincial and territorial governments have
primary jurisdiction in the administration and delivery of
health care services. This includes setting their own priorities,
administering their health care budgets and managing their
own resources. The federal government, under the Canada
Health Act, sets out the criteria and conditions that must be
satisfied by the provincial and territorial health insurance plans
for provinces and territories to qualify for their full share of the
cash contribution available to them under the federal Canada
Health Transfer.
On an annual basis, the federal Minister of Health is required
to report to Parliament on the administration and operation of
the Canada Health Act, as set out in section 23 of the Act. The
vehicle for so doing is the Canada Health Act Annual Report.
While the principal and intended audience for the annual
report is Parliamentarians, it is a public document that offers
a comprehensive description of insured health services in each
of the provinces and territories. The annual report is structured
to address the mandated reporting requirements of the Act; as
such, its scope does not extend to commenting on the status of
the Canadian health care system as a whole.
Provincial and territorial health care insurance plans generally
respect the criteria and conditions of the Canada Health Act
and many exceed the requirements of the Act. However,
when instances of possible non-compliance with the Act
arise, Health Canada’s approach to the administration of the
Act emphasizes transparency, consultation and dialogue with
provincial and territorial health care ministries. The application
of financial penalties through deductions under the Canada
Health Transfer is considered only as a last resort when all
other options to resolve an issue collaboratively have been
exhausted. Pursuant to the commitment made by premiers
under the 1999 Social Union Framework Agreement, federal,
provincial and territorial governments (except Quebec) agreed
through an exchange of letters, in April 2002, to a Canada
Health Act Dispute Avoidance and Resolution (DAR) process.
The DAR process was formalized in the First Ministers’ 2004
Accord. Although the DAR process includes dispute resolution
provisions, the federal Minister of Health retains the final
authority to interpret and enforce the Canada Health Act.
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CHAPTER 1
CANADA HEALTH ACT OVERVIEW
This section describes the Canada Health Act, its requirements,
key definitions, regulations and regulatory provisions, letters by
former federal Ministers of Health Jake Epp and Diane Marleau
to their provincial and territorial counterparts that are used in
the interpretation and application of the Act, and the letter from
former federal Minister, A. Anne McLellan, to her provincial
and territorial counterparts on the Canada Health Act Dispute
Avoidance and Resolution process. A history of the evolution
of federal health care transfers follows.
WHAT IS THE CANADA
HEALTH ACT?
The Canada Health Act is Canada’s federal legislation for
publicly funded health care insurance. The Act sets out the
primary objective of Canadian health care policy, which is
“to protect, promote and restore the physical and mental wellbeing of residents of Canada and to facilitate reasonable access
to health services without financial or other barriers.”
The Act establishes criteria and conditions related to insured
health services and extended health care services that the
provinces and territories must fulfill to receive the full federal
cash contribution under the Canada Health Transfer (CHT).
The aim of the Act is to ensure that all eligible residents of
Canadian provinces and territories have reasonable access to
medically necessary hospital and physician services on a prepaid
basis, without charges related to the provision of insured
health services.
Key Definitions Under the Canada Health Act
Insured persons are eligible residents of a province or territory.
A resident of a province is defined in the Act as “a person
lawfully entitled to be or to remain in Canada who makes his
home and is ordinarily present in the province, but does not
include a tourist, a transient or a visitor to the province.”
Persons excluded under the Act include serving members of
the Canadian Forces and inmates of federal penitentiaries.
Insured health services are medically necessary hospital,
physician and surgical-dental services (performed by a dentist
in a hospital, where a hospital is required for the proper
performance of the procedure) provided to insured persons.
Insured hospital services are defined under the Act and
include medically necessary in- and out-patient services such
as accommodation and meals at the standard or public ward
level and preferred accommodation if medically required;
nursing service; laboratory, radiological and other diagnostic
procedures, together with the necessary interpretations; drugs,
biologicals and related preparations when administered in the
hospital; use of operating room, case room and anaesthetic
facilities, including necessary equipment and supplies; medical
and surgical equipment and supplies; use of radiotherapy
facilities; use of physiotherapy facilities; and services provided
by persons who receive remuneration therefor from the
hospital, but does not include services that are excluded
by the regulations.
Insured physician services are defined under the Act as
“medically required services rendered by medical practitioners.”
Medically required physician services are generally determined
by the provincial or territorial health insurance plan, in
conjunction with the medical profession.
Insured surgical-dental services are services provided by a
dentist in a hospital, where a hospital setting is required to
properly perform the procedure.
Extended health care services, as defined in the Act, are
certain aspects of long-term residential care (nursing home
intermediate care and adult residential care services), and the
health aspects of home care and ambulatory care services.
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REQUIREMENTS OF THE
CANADA HEALTH ACT
The Canada Health Act contains nine requirements that the
provinces and territories must fulfill in order to qualify for
the full amount of their cash entitlement under the CHT.
They are:
■■ five program criteria that apply only to insured health
services;
■■ two conditions that apply to insured health services and
extended health care services; and
■■ extra-billing and user charges provisions that apply only
to insured health services.
The Criteria
1. Public Administration (section 8)
The public administration criterion requires provincial and
territorial health care insurance plans to be administered and
operated on a non-profit basis by a public authority, which
is accountable to the provincial or territorial government for
decision-making on benefit levels and services, and whose records
and accounts are publicly audited. However, the criterion does
not prevent the public authority from contracting out the services
necessary for the administration of the provincial and territorial
health care insurance plans.
The public administration criterion pertains only to the
administration of P/T health insurance plans and does not
preclude private facilities or providers from supplying insured
health services as long as no insured person is charged in
relation to these services.
2. Comprehensiveness (section 9)
The comprehensiveness criterion of the Act requires that the
health care insurance plan of a province or territory must cover
all insured health services provided by hospitals, physicians
or dentists (i.e., surgical-dental services that require a
hospital setting).
3. Universality (section 10)
Under the universality criterion, all insured residents of a
province or territory must be entitled to the insured health
services provided by the provincial or territorial health care
insurance plan on uniform terms and conditions. Provinces
and territories generally require that residents register with
the plan to establish entitlement.
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4. Portability (section 11)
Residents moving from one province or territory to another
must continue to be covered for insured health services by
the “home” jurisdiction during any waiting period (up to
three months) imposed by the new province or territory of
residence. It is the responsibility of residents to inform their
province or territory’s health care insurance plan that they are
leaving and to register with the health care insurance plan of
their new province or territory.
Residents who are temporarily absent from their home province
or territory or from Canada, must continue to be covered for
insured health services during their absence. If insured persons
are temporarily absent in another province or territory, the
portability criterion requires that insured services be paid at
the host province’s rate. If insured persons are temporarily
out of the country, insured services are to be paid at the home
province’s rate.
The portability criterion does not entitle a person to seek
services in another province, territory or country, but is
intended to permit a person to receive necessary services
in relation to an urgent or emergent need when absent on
a temporary basis, such as on business or vacation.
Prior approval by the health care insurance plan in a person’s
home province or territory may be required before coverage is
extended for elective (non-emergency) services to a resident
while temporarily absent from their province or territory.
5. Accessibility (section 12)
The intent of the accessibility criterion is to ensure that insured
persons in a province or territory have reasonable access to
insured hospital, medical and surgical-dental services on uniform
terms and conditions, unprecluded or unimpeded, either directly
or indirectly, by charges (user charges or extra-billing) or other
means (e.g., discrimination on the basis of age, health status or
financial circumstances).
Reasonable access in terms of physical availability of medically
necessary services has been interpreted under the Canada
Health Act using the “where and as available” rule. Thus,
residents of a province or territory are entitled to have access on
uniform terms and conditions to insured health services at the
setting “where” the services are provided and “as” the services
are available in that setting.
In addition, the health care insurance plans of the province or
territory must provide:
■■ reasonable compensation to physicians and dentists for all
the insured health services they provide; and
■■ payment to hospitals to cover the cost of insured health
services.
CHAPTER 1: CANADA HEALTH ACT OVERVIEW
The Conditions
User Charges (section 19)
1. Information (section 13(a))
The Act defines user charges as any charge for an insured
health service, other than extra-billing. For example, if patients
were charged a facility fee for the non-physician (i.e., hospital)
services provided in conjunction with a physician service that is
insured under the provincial health insurance plan at a clinic,
that fee would be considered a user charge. User charges are
not permitted under the Act because, as is the case with extrabilling, they constitute a barrier or impediment to access.
The provincial and territorial governments are required to
provide information to the federal Minister of Health as
prescribed by regulations under the Act.
2. Recognition (section 13(b))
The provincial and territorial governments are required to
recognize the federal financial contributions toward both
insured and extended health care services.
OTHER ELEMENTS OF THE ACT
Extra-billing and User Charges
Regulations (section 22)
The provisions of the Canada Health Act pertaining to extrabilling and user charges for insured health services in a
province or territory are outlined in sections 18 to 21. If it
can be confirmed that either extra-billing or user charges
exist in a province or territory, a mandatory deduction from
the federal cash transfer to that province or territory is
required under the Act. The amount of such a deduction for
a fiscal year is determined by the federal Minister of Health.
This can be based on information provided by the province
or territory in accordance with the Extra-billing and User
Charges Information Regulations (described below). Section
20 of the Act requires the Minister to make an estimate of the
amount of extra-billing and user charges where information
is not provided in accordance with the regulations. This
process requires the Minister to consult with the province
or territory concerned.
Section 22 of the Canada Health Act enables the federal
government to make regulations for administering the Act
in the following areas:
Extra-billing (section 18)
Under the Act, extra-billing is defined as the billing for an
insured health service rendered to an insured person by a
medical practitioner or a dentist (i.e., a dentist providing
insured surgical-dental services in a hospital setting) in an
amount in addition to any amount paid or to be paid for that
service by the health care insurance plan of a province or
territory. For example, if a physician was to charge a patient
any amount for an office visit that is insured by the provincial
or territorial health insurance plan, the amount charged would
constitute extra-billing. Extra-billing is seen as a barrier or
impediment for people seeking medical care, and is therefore
also contrary to the accessibility criterion.
■■ defining the services included in the Act’s definition of
“extended health care services,” e.g., nursing home care or
home care;
■■ prescribing which services are excluded from hospital services;
■■ prescribing the types of information that the federal
Minister of Health may reasonably require, as well as the
format and submission deadline for the information; and
■■ prescribing how provinces and territories are required
to recognize the CHT in their documents, advertising
or promotional materials.
To date, the only regulations in force under the Act are the
Extra-billing and User Charges Information Regulations.
These regulations require the provinces and territories to
annually report to Health Canada amounts of extra-billing
and user charges levied. A copy of these regulations is provided
in Annex A.
Penalty Provisions of the Canada Health Act
Mandatory Penalty Provisions
Under the Act, provinces and territories that allow extra-billing
and user charges are subject to mandatory dollar-for-dollar
deductions from the federal transfer payments under the CHT.
In plain terms, this means that when it has been determined
that a province or territory has allowed $500,000 in extrabilling by physicians, the federal cash contribution to that
province or territory will be reduced by that same amount.
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CHAPTER 1: CANADA HEALTH ACT OVERVIEW
Discretionary Penalty Provisions
Excluded Persons
Non-compliance with one of the five criteria or two conditions
of the Act is subject to a discretionary penalty. The amount of
any deduction from federal transfer payments under the CHT
is based on the magnitude of the non-compliance.
The Canada Health Act definition of “insured person” excludes
members of the Canadian Forces and persons serving a term of
imprisonment within a federal penitentiary. The Government
of Canada provides coverage to these groups through separate
federal programs.
The Canada Health Act sets out a consultation process that must
be undertaken with the province or territory before discretionary
penalties can be levied. To date, the discretionary penalty
provisions of the Act have not been applied.
EXCLUDED SERVICES
AND PERSONS
Although the Canada Health Act requires that insured health
services be provided to insured persons in a manner that is
consistent with the criteria and conditions set out in the Act,
not all Canadian residents or health services fall under the
scope of the Act.
Excluded Services
A number of services provided by hospitals and physicians are
not considered medically necessary, and thus are not insured
under provincial and territorial health insurance legislation.
Uninsured hospital services for which patients may be charged
include preferred hospital accommodation unless prescribed
by a physician or when standard ward level accommodation
is unavailable, private duty nursing services and the provision
of telephones and televisions. Uninsured physician services
for which patients may be charged include telephone advice;
the provision of medical certificates required for work, school,
insurance purposes and fitness clubs; testimony in court; and
cosmetic services.
In addition, the definition of “insured health services” excludes
services to persons provided under any other Act of Parliament
(e.g., inmates of federal penitentiaries) or under the workers’
compensation legislation of a province or territory.
In addition to the medically necessary hospital and physician
services covered by the Canada Health Act, provinces and
territories also provide a range of other programs and services.
These are provided at provincial and territorial discretion, on
their own terms and conditions, and vary from one province or
territory to another. Additional services that may be provided
include pharmacare, ambulance services and optometric
services. The additional services provided by provinces and
territories are often targeted to specific population groups
(e.g., children, seniors or social assistance recipients), and may
be partially or fully covered by the province or territory.
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The exclusion of these persons from insured health service
coverage predates the adoption of the Act and is not intended
to constitute differences in access to publicly insured health care.
There is a Frequently Asked Questions link on Health Canada’s
web-site to address common concerns that Canadians might
have about Canada’s publicly funded health insurance plans.
See: http://hc-sc.gc.ca/hcs-sss/medi-assur/faq-eng.php
POLICY INTERPRETATION
LETTERS
There are two key policy statements that clarify the federal
position on the Canada Health Act. These statements were made
in the form of ministerial letters from former federal Ministers
of Health to their provincial and territorial counterparts. Both
letters are reproduced in Annex B of this report.
Epp Letter
In June 1985, approximately one year following the passage of
the Canada Health Act in Parliament, federal Minister of Health
and Welfare Jake Epp wrote to his provincial and territorial
counterparts to set out and confirm the federal position on the
interpretation and implementation of the Act
Minister Epp’s letter followed several months of consultation
with his provincial and territorial counterparts. The letter
sets forth statements of federal policy intent that clarify the
Act’s criteria, conditions and regulatory provisions. These
clarifications have been used by the federal government in
assessing and interpreting compliance with the Act. The Epp
letter remains an important reference for interpreting the Act.
Marleau Letter — Federal Policy on
Private Clinics
Between February 1994 and December 1994, a series of seven
federal/provincial/territorial meetings dealing wholly, or in
part, with private clinics took place. At issue was the growth
of private clinics providing medically necessary services funded
partially by the public system and partially by patients, and
their impact on Canada’s universal, publicly funded health
care system.
CHAPTER 1: CANADA HEALTH ACT OVERVIEW
At the September 1994 federal/provincial/territorial meeting
of health ministers in Halifax, all ministers of health present,
with the exception of Alberta’s health minister, agreed to
“take whatever steps are required to regulate the development
of private clinics in Canada.”
Diane Marleau, the federal Minister of Health at the time,
wrote to all provincial and territorial ministers of health on
January 6, 1995, to announce the new Federal Policy on Private
Clinics. The Minister’s letter provided the federal interpretation
of the Canada Health Act as it relates to the issue of facility
fees charged directly to patients receiving medically necessary
services at private clinics. The letter stated that the definition
of “hospital” contained in the Act includes any public facility
that provides acute, rehabilitative or chronic care. Thus, when a
provincial or territorial health insurance plan pays the physician
fee for a medically necessary service delivered at a private clinic,
it must also pay the facility fee or face a deduction from federal
transfer payments.
DISPUTE AVOIDANCE AND
RESOLUTION PROCESS
In April 2002, federal Minister of Health A. Anne McLellan
outlined in a letter to her provincial and territorial counterparts
a Canada Health Act Dispute Avoidance and Resolution
process, which was agreed to by provinces and territories, except
Quebec. The process meets federal and provincial or territorial
interests of avoiding disputes related to the interpretation of the
principles of the Act and, when this is not possible, resolving
disputes in a fair, transparent and timely manner.
The process includes the dispute avoidance activities of
government-to-government information exchange; discussions
and clarification of issues as they arise; active participation
of governments in ad hoc federal/provincial/territorial
committees on Act-related issues; and Canada Health Act
advance assessments, upon request.
Where dispute avoidance activities prove unsuccessful,
dispute resolution activities may be initiated, beginning with
government-to-government fact-finding and negotiations. If
these are unsuccessful, either minister of health involved may
refer the issues to a third-party panel to undertake fact-finding
and provide advice and recommendations.
The federal Minister of Health has the final authority to
interpret and enforce the Canada Health Act. In deciding
whether to invoke the non-compliance provisions of the Act,
the Minister will take the panel’s report into consideration.
A copy of Minister McLellan’s letter is included in Annex C
of this report.
EVOLUTION OF FEDERAL
HEALTH CARE TRANSFERS
Grants To Help Establish Programs and
Cost-Sharing
Federal support for provincial health care goes back to the
late 1940s when the National Health Grants were created.
These grants were considered to be essential building blocks
of a national health care system. While the grants were
mainly used to build up the Canadian hospital infrastructure,
they also supported initiatives in areas such as professional
training, public health research, tuberculosis control and
cancer treatment. By the mid-1960s, the grants available
to the provinces totalled more than $60 million annually.
In the mid-1950s in response to public pressures, the
federal government agreed to provide financial assistance to
provinces to help them establish health insurance programs.
In January 1956, the federal government placed concrete
proposals before the provinces to inaugurate a phased health
insurance program, with priority given to hospital insurance
and diagnostic services. Discussions on these proposals led to
the adoption of the Hospital Insurance and Diagnostic Services Act
(HIDSA) in 1957. The implementation of the HIDSA started
in July 1958, by which time Newfoundland, Saskatchewan,
Alberta, British Columbia and Manitoba were operating
hospital insurance plans. By 1961, all provinces and territories
were participating in the program.
The second phase of the federal intervention supporting
provincial and territorial health insurance programs resulted
from the recommendations of the Royal Commission on Health
Services (Hall Commission). In its final report, tabled in 1964,
the Hall Commission recommended establishing a new program
that would ensure that all Canadians have access to necessary
medical care (physician services, outside a hospital setting).
The Medical Care Act was introduced in Parliament in
July 1966, and received Royal Assent on December 21, 1966.
The implementation of the Medical Care program started
on July 1, 1968. By 1972, all provinces and territories were
participating in the program.
Originally, the federal government’s method of contributing
to provincial and territorial hospital insurance programs was
based on the cost to provinces and territories of providing
insured hospital services. Under the HIDSA (1957), the
federal government reimbursed the provinces and territories
for approximately 50 percent of the costs of hospital insurance.
In both cases, funding was conditional on certain program
criteria being met. Under the Medical Care Act (1966),
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CHAPTER 1: CANADA HEALTH ACT OVERVIEW
the federal contribution was set at 50 percent of the average
national per capita costs of the insured services, multiplied
by the number of insured persons in each province and territory.
Funding protocols based on conditional grants continued until
the move to block funding was made in fiscal year 1977–1978.
Canada Health and Social Transfer
Established Programs Financing
The new omnibus or block transfer, beginning in fiscal year
1996–1997, merged the health and post-secondary education
funding of the EPF Act with Canada Assistance Plan funding
(the federal/provincial cost-sharing arrangement for social
services). When the CHST came into effect on April 1, 1996,
provinces and territories received CHST cash and tax transfer
in lieu of entitlements under the Canada Assistance Plan
(CAP) and EPF. The new CHST cash amount provided to
provinces and territories was less than the combined values
of EPF and CAP, reflecting the need for fiscal restraint at
the time the CHST was introduced. The 1995 and 1996
Budget legislation provided for total CHST amounts (cash
and tax transfers) for subsequent years, with an annual floor of
$11 billion for the cash component to apply until 2002–2003.
On April 1, 1977, federal funding supporting insured health care
services was replaced by a block fund transfer with only general
requirements related to maintaining a minimum standard of
health services through the passage of the Federal-Provincial
Fiscal Arrangements and Established Programs Financing Act,
1977. Known also as the EPF Act, the new legislation provided
federal contributions to the provinces and territories for insured
hospital and medical care services (as well as for post-secondary
education) that were no longer tied to provincial expenditures.
Rather, federal contributions made in fiscal year 1975–1976 under
the existing cost-sharing programs were designated as the base
year for contributions, to be escalated by the rate of growth of
nominal Gross National Product and increases to the population.
Under the EPF Act, and subsequent funding arrangements, the
total amount of the provincial and territorial health entitlement
was made up of relatively equal cash and tax transfers. The
federal tax transfer involves the federal government ceding
some of its “tax room” to the provincial and territorial
governments, reducing its tax rate to allow provinces to raise
their tax rates by an equivalent amount. With the Established
Programs Financing “health” tax transfer, the changes in
federal and provincial tax rates offset one another, meaning
there was no net impact on taxpayers. The total amount of the
health care entitlement did not change.
The EPF Act also included a new transfer for the Extended
Health Care Services Program. This group of health care
services, defined as nursing home intermediate care, adult
residential care, ambulatory health care and the health aspects
of home care, were block funded on the basis of $20 per capita
for fiscal year 1977–1978, and subject to the same escalator
as insured health services. This portion of the EPF transfer
was made on a virtually unconditional basis and, unlike the
insured services transfer, was not subject to specified program
delivery criteria.
Under the prevailing legislative framework, the Government
of Canada was required to withhold all of the monthly health
care transfer to a province or territory for each month the
program delivery criteria were not met. It was not until the
enactment of the Canada Health Act in 1984 that special
deduction provisions came into force allowing for dollarfor-dollar deductions for extra-billing and user charges,
and discretionary deductions when provincial and territorial
plans failed to fully comply with other provisions set out in
the Act. These criteria and conditions remain in force to the
present day.
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CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
In the 1995 Budget, the federal government announced a
restructuring of the EPF Act, from then on to be called the
Federal-Provincial Fiscal Arrangements Act, with provisions
for a Canada Health and Social Transfer (CHST).
The new block fund was provided to uphold the national
criteria in the Canada Health Act (public administration,
comprehensiveness, universality, portability and accessibility)
and the provisions relating to extra-billing and user charges,
as well as maintaining the CAP-related national standard
that no period of minimum residency be required or allowed
with respect to social assistance. Extended health care services
continued as part of the Act, subject only to the conditions of
providing information and recognizing the federal transfer,
as set out in section 13 of the Act.
The new legislation also transferred the cash payment authority
from Health Canada to the Department of Finance. However,
the federal Minister of Health continued to be responsible for:
■■ recommending the amounts of any deductions or with­
holdings pursuant to the conditions and criteria of the Act
to the Governor in Council;
■■ determining the amounts of any deductions pursuant to the
extra-billing and user charges provisions of the Act; and
■■ ensuring that these amounts are communicated to the
Department of Finance before the CHST payment dates.
From 1997 to 2000, there were several increases to the cash
portion of the CHST, including increases to the cash floor.
In 1998, the cash floor was increased to $12.5 billion. With
the federal government’s return to surpluses, Budget 1999
announced an additional $11.5 billion for health care. Of
this amount, $8 billion was provided in CHST cash over the
following four years. The remaining $3.5 billion was provided
through a trust fund notionally allocated over three years to
provide provinces and territories flexibility over when to draw
down the funds. Budget 2000 then provided an additional
$2.5 billion for health care through another trust fund to
provinces and territories, notionally allocated over four years.
CHAPTER 1: CANADA HEALTH ACT OVERVIEW
2000 and 2003 Health Accords: Increasing and
Restructuring Federal Support for Health
In 2000 and 2003, First Ministers met to discuss health care,
focusing on reform, reporting and funding requirements. In
2000, the federal government announced $23.4 billion in
new spending over five years on health care renewal and early
childhood development. This included an additional $21.1 billion
dollars in increases to the CHST cash contributions, as well as an
additional $1.8 billion for targeted programs (medical equipment
and primary health care reform), and $500 million for Canada
Health Infoway.
In 2003, the government committed $36.8 billion over five
years to support priority areas of health reform (primary care,
home care and catastrophic drugs). This was provided through
$14 billion in increased CHST transfers and $16 billion for
the Health Reform Transfer, as well as $1.5 billion for medical
equipment. This was in addition to $5.3 billion in federal direct
spending on health information technologies, Aboriginal
health initiatives, patient safety and other health-related
federal initiatives.
The federal government also agreed to restructure the CHST to
enhance the transparency and accountability of federal support
for health.
The Canada Health Transfer
The CHST was restructured into two new transfers, the Canada
Health Transfer (CHT) and Canada Social Transfer (CST),
effective April 1, 2004. The CHT supports the Government of
Canada’s ongoing commitment to maintain the national criteria
and conditions of the Canada Health Act. The CST; a block fund
that supports post-secondary education and social assistance
and social services, continues to give provinces and territories
the flexibility to allocate funds among these social programs
according to their respective priorities.
The existing CHST-legislated amounts were apportioned
between the new transfers, with the percentage of cash and
tax points allocated to each transfer reflecting provincial and
territorial spending patterns among the areas supported by the
transfers: 62 percent for the CHT and 38 percent for the CST.
2004 10-year Plan to Strengthen Health Care
Federal transfers to the provinces and territories were further
increased as a result of the 10-Year Plan to Strengthen Health
Care. Signed by all first Ministers on September 16, 2004,
this initiative committed the Government of Canada to
an additional $41.3 billion in funding, over ten years until
2013–2014, to the provinces and territories for health. This
included $35.3 billion in increases to the CHT, $5.5 billion
in Wait Times Reduction funding, and $500 million in
support of diagnostic and medical equipment.
Budget 2007
To restore fiscal balance in Canada, Budget 2007 put all major
transfers on a long-term, principles-based track to 2013–2014.
In order to provide comparable treatment for all Canadians,
regardless of where they live the budget legislated equal per
capita cash support for the CST, starting in 2007–2008, and the
CHT, starting after the 10-Year Plan to Strengthen Health Care
concludes in 2013–2014. In addition, Budget 2007 invested an
additional $1 billion to help provinces and territories introduce
wait time guarantees, including initiatives delivered through
Canada Health Infoway.
Recent Transfer Changes
As announced by the Government of Canada in December 2011,
and legislated in the Jobs, Growth and Long-term Prosperity Act,
the CHT will continue to grow at an annual rate of 6 percent
for an additional three years beyond 2013–2014 (i.e., until
2016–2017). Starting in 2017–2018, the CHT will grow in line
with a three-year moving average of nominal gross domestic
product growth, with funding guaranteed to increase by at least
three percent per year.
Following up on the 2007 legislation for a transition to an equal
per capita cash allocation for the CHT in 2014–2015, the Jobs,
Growth and Long-term Prosperity Act ensured a fiscally responsible
transition by providing protection so that no province or territory
will receive less than its 2013–2014 CHT cash allocation in
subsequent years as a result of the move to equal per capita cash.
Additional information on federal-provincial-territorial
funding arrangements is available upon request from
the Department of Finance, or by visiting its website at:
www.fin.gc.ca/access/fedprov-eng.asp#Major
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
9
10
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
CHAPTER 2
ADMINISTRATION
AND COMPLIANCE
ADMINISTRATION
■■ working with Health Canada Legal Services and Justice
In administering the Canada Health Act (CHA), the federal
Minister of Health is assisted by Health Canada staff at
headquarters and in the regions, and by the Department
of Justice.
Interprovincial Health Insurance
Agreements Coordinating Committee
The Canada Health Act Division
The Canada Health Act Division of Health Canada is responsible
for administering the CHA. Members of the Division fulfill the
following ongoing functions:
■■ monitoring and analysing provincial and territorial health
insurance plans for compliance with the criteria, conditions,
and extra-billing and user charges provisions of the CHA;
■■ disseminating information on the CHA and on publicly
funded health care insurance programs in Canada;
■■ responding to inquiries about the CHA and health insurance
issues received by telephone, mail and the Internet, from the
public, members of Parliament, government departments,
stakeholder organizations and the media;
■■ developing and maintaining formal and informal partnerships
with health officials in provincial and territorial governments
for information sharing;
■■ producing the Canada Health Act Annual Report on the
administration and operation of the CHA;
■■ conducting issue analysis and policy research to provide
policy advice;
Canada on litigation issues that implicate the CHA.
The Interprovincial Health Insurance Agreement Coordinating
Committee (IHIACC) was formed in 1991 to address issues
affecting the interprovincial billing of insured hospital and
physician services. The Committee includes members from
each province and territory and a non-voting chair from
the Canada Health Act Division. The Canada Health Act
Division also provides secretariat functions for IHIACC.
Through IHIACC, all provinces and territories participate in
reciprocal hospital agreements, and all, with the exception of
Quebec, participate in reciprocal physician agreements. These
agreements generally ensure that a patient’s health card will be
accepted, in lieu of payment, when the patient receives insured
hospital or physician services in another province or territory.
The province or territory providing the service will then directly
bill the patient’s home province. The intent of these agreements
is to ensure that Canadian residents do not have to pay directly
for medically required hospital and physician services when
they travel within Canada.
IHIACC’s Rate Review Working Group is responsible for
determining reciprocal billing rates to ensure that the host
province or territory that is providing the health service is
compensated by the home province at a reasonable rate.
■■ working in partnership with the provinces and territories
Issues related to registration and eligibility requirements are
addressed through IHIACC’s Eligibility and Portability
Working Group that is responsible for reviewing eligibility
issues and identifying potential inter-jurisdictional gaps in
health coverage.
■■ informing the federal Minister of Health of possible
Of note, these agreements are interprovincial, not federal,
and while they facilitate the portability criterion they are not
a requirement of the CHA.
■■ collaborating with provincial and territorial health department
representatives through the Interprovincial Health Insurance
Agreements Coordinating Committee (see below);
to investigate and resolve compliance issues and pursue
activities that encourage compliance with the CHA;
non-compliance and recommending appropriate action
to resolve the issue; and
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
11
CHAPTER 2: ADMINISTRATION AND COMPLIANCE
COMPLIANCE
Health Canada’s approach to resolving possible compliance
issues emphasizes transparency, consultation and dialogue
with provincial and territorial health ministry officials. In
most instances, issues are successfully resolved through
consultation and discussion based on a thorough examination
of the facts.
The Canada Health Act Division monitors the operations of
provincial and territorial health care insurance plans in order to
provide advice to the Minister on possible non-compliance with
the Canada Health Act (CHA). Sources for this information
include: provincial and territorial government officials and
publications; media reports; and correspondence received from
the public and non-governmental organizations.
Staff in the Compliance and Interpretation Unit of the Canada
Health Act Division assess issues of concern and complaints on
a case-by-case basis. The assessment process involves compiling
all facts and information related to the issue and taking
appropriate action. Verifying the facts with provincial and
territorial health officials may reveal issues that are not directly
related to the CHA, while others may pertain to the CHA but
are a result of misunderstanding or miscommunication, such
as eligibility for health insurance coverage and portability of
health services within and outside Canada, and are resolved
quickly with provincial or territorial assistance.
In instances where a CHA issue has been identified and
remains after initial enquiries, Division officials ask the
jurisdiction in question to investigate the matter and report
back. Division staff discuss the issue and its possible resolution
with provincial or territorial officials. Only if the issue is not
resolved to the satisfaction of the Division after following
the aforementioned steps, is it brought to the attention of the
federal Minister of Health.
COMPLIANCE ISSUES
For the most part, provincial and territorial health care
insurance plans meet the criteria and conditions of the
Canada Health Act (CHA). However, on the basis of their
health ministry’s report to Health Canada, a deduction in the
amount of $241,637 was taken from the March 2015 Canada
Health Transfer payments to British Columbia in respect of
extra-billing and user charges for insured health services at
private clinics in fiscal year 2012–2013.
Health Canada continues to monitor provincial and territorial
compliance with the CHA. The following key developments
occurred since the 2013–2014 Canada Health Act Annual
Report was published:
12
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
Under the CHA, the definition of “hospital services” specifies
that standard or public ward level accommodation is an
insured service. Charges for preferred accommodation are
permissible under the CHA only where such accommodation
is not medically required, and is provided at the patient’s
request. If ward level accommodation is not available or
cannot be offered, patients must be provided private or semiprivate accommodation at no charge. In January 2014, Health
Canada learned that two hospitals are being built in Quebec
that will have only semi-private and private rooms, and that
the Quebec health ministry considered permitting these
hospitals to charge fees for all stays. Health Canada reviewed
the applicable provincial and territorial legislation and policies
and found similar practices in Ontario and British Columbia.
In July 2014, Health Canada informed the health ministries of
British Columbia, Ontario and Quebec that such charges are
contrary to the CHA. British Columbia has since corrected
the problem, while Ontario and Quebec are still examining
the issue.
As detailed in the 2013–2014 Canada Health Act Annual
Report, in January 2011, the Vancouver General Hospital in
British Columbia began charging patients a fee when they
elect to have robot-assisted surgery versus the conventional
surgical alternative for certain medically necessary procedures
(e.g., prostatectomy, hysterectomy). In October 2013, Health
Canada informed the British Columbia health ministry that
since the robot is a piece of surgical equipment used to perform
an insured hospital service, it falls within the definition of
insured hospital services under the CHA. For that reason,
there should be no patient charges. In December 2014, the
BC Health Ministry wrote to Health Canada to confirm
that it had directed the hospital to cease charging patients
for robot-assisted surgeries by January 31, 2015.
During 2014–2015, Health Canada continued to consult with
Alberta Health about private primary health care clinics that
charge patients annual enrollment and membership fees. If
the receipt of insured services is conditional upon the payment
of fees, it would pose concerns under the accessibility criterion
of the CHA. Typically, the fees cover a basket of uninsured
services but also promise quick access to and unrushed
appointments with family physicians. In November 2013,
Alberta Health informed Health Canada that it had
completed an audit of an Edmonton clinic, which resulted in
the clinic better communicating with patients about charges
for uninsured services. Alberta Health conducted similar
audits at two other clinics and shared the results of all three
audits with Health Canada in January 2015. In March 2015,
Health Canada requested confirmation that processes were in
place to reimburse patients who had been charged for insured
services and that such charges had ceased. As well, the Alberta
College of Physicians and Surgeons continues to consider new
or amended practice standards to guide physicians involved in
these arrangements.
CHAPTER 2: ADMINISTRATION AND COMPLIANCE
In November 2014, Health Canada provided an advance
assessment under the CHA to Nova Scotia on a proposal by
some ophthalmologists to charge patients for certain tests when
they are performed in the physician’s office instead of a hospital,
in respect of the cost of the technology used. Health Canada
confirmed that no additional fees can be charged in conjunction
with a medically necessary physician service.
Also in November 2014, Prince Edward Island asked Health
Canada if there would be CHA implications if a proposed
non-profit clinic were funded by a charitable foundation,
where health services would be provided without a charge
to patients by a nurse practitioner. Health Canada informed
Prince Edward Island that since the services were neither
provided by physicians nor in a hospital, they are not under
the ambit of the CHA. Had patients been charged directly for
these services, Health Canada would have concerns about the
migration of physician services to settings in which insured
residents must pay to receive them.
In March 2014, Health Canada asked the Ministry of Health
and Long-term Care in Ontario for its assessment of illegal
patient charges alleged by the Ontario Health Coalition in its
report, “For Health or Wealth.” Health Canada also inquired
if the My Health Report web-based service allows subscribers
to obtain expedited access to insured physician services. On
August 8, 2014, the Ontario health ministry replied, saying
that no evidence of illegal charges alleged by the Ontario
Health Coalition was found. The Ontario health ministry also
noted that it has published information bulletins to physicians,
hospitals and licensed independent health facilities, to remind
them of the prohibitions on extra-billing and user charges, as
well as queue-jumping, under the Ontario Commitment to the
Future of Medicare Act and the Independent Health Facilities Act.
With regards to the My Health Report web-based service,
Ontario noted that the description of services on the
web-site no longer includes a reference to expedited care.
In both of these cases, Health Canada considers these issues
to be resolved.
In March 2015, Health Canada wrote to the Quebec Ministry
of Health concerning patient charges by physicians, when they
provide certain publicly insured health services in their offices
or private clinics. Health Canada’s consultation with Quebec
on this issue is ongoing.
During 2014–2015, Health Canada continued to monitor the
following ongoing compliance and interpretation issues:
Abortion services are insured in all provinces and territories;
however, access to these insured services varies within and
between jurisdictions across the country. In Prince Edward
Island and New Brunswick, the services are only covered if
performed in a hospital (for example, private clinic procedures
are not covered). In addition, Prince Edward Island lacks
abortion services on the island and residents must travel off the
island to access them. In New Brunswick, access has improved
because certification of medical necessity by two physicians,
and performance of the service by a specialist in gynecology or
obstetrics in a hospital are no longer required. Prince Edward
Island service has improved because the province has eliminated
the need for a referral from an Island doctor and now allows
women to self-refer to a Moncton, New Brunswick, hospital.
However, accessibility and comprehensiveness concerns remain
because neither province covers private clinic abortions under
their respective provincial health insurance plans.
Health Canada remains concerned about patient payments for
drugs administered in hospital out-patient clinics and their
appropriateness under the CHA, since drugs and biological
products administered in hospitals that are medically necessary
for the purpose of maintaining health, preventing disease or
diagnosing or treating an injury, illness or disability are insured
health services under the CHA.
MRI and CT services are also considered to be insured health
services when they are medically necessary for the purpose
of maintaining health, preventing disease or diagnosing or
treating an injury, illness or disability, and are provided in
a hospital or a facility providing hospital care, but patient
charges for these services are levied by private clinics in
British Columbia, Alberta, Quebec, New Brunswick and
Nova Scotia.
Physician services received by Quebec residents when out-ofprovince are not reimbursed at host province rates, which is a
requirement of the portability criterion of the CHA. Canadians
from provinces other than Quebec also report difficulties having
their provincial or territorial health insurance cards honoured
while out-of-province, particularly by walk-in clinics, which
runs counter to the spirit of the CHA. For all jurisdictions,
except Prince Edward Island and the three territories, the per
diem rates for out-of-country hospital services appear lower than
home province or territory rates, which is also a requirement of
the portability criterion of the CHA.
HISTORY OF DEDUCTIONS
AND REFUNDS UNDER THE
CANADA HEALTH ACT
The Canada Health Act (CHA), which came into force
April 1, 1984, reaffirmed the national commitment to the
original principles of the Canadian health care system, as
embodied in the previous legislation, the Medical Care Act
and the Hospital Insurance and Diagnostic Services Act.
By putting into place mandatory dollar-for-dollar penalties
for extra-billing and user charges, the federal government
took steps to eliminate the proliferation of direct charges
for hospital and physician services, judged to be restricting
the access of many Canadians to health care services due
to financial considerations.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
13
CHAPTER 2: ADMINISTRATION AND COMPLIANCE
During the period 1984 to 1987, subsection 20(5) of
the CHA provided for deductions in respect of these
charges to be refunded to the province if the charges were
eliminated before April 1, 1987. By March 31, 1987, it
was determined that all provinces, which had extra-billing
and user charges, had taken appropriate steps to eliminate
them. Accordingly, by June 1987, a total of $244,732,000 in
deductions was refunded to New Brunswick ($6,886,000),
Quebec ($14,032,000), Ontario ($106,656,000), Manitoba
($1,270,000), Saskatchewan ($2,107,000), Alberta
($29,032,000) and British Columbia ($84,749,000).
Following the CHA’s initial three-year transition period,
under which refunds to provinces and territories for deductions
were possible, penalties under the CHA did not reoccur until
fiscal year 1994–1995. Please refer to the table at the end of
this section for a summary of deductions and refunds that
have been made to provincial or territorial transfer payments
since 1994–1995.
In the early 1990s, as a result of a dispute between
the British Columbia Medical Association and the
British Columbia government over compensation, several
doctors opted out of the provincial health insurance plan and
began billing their patients directly. Some of these doctors
billed their patients at a rate greater than the amount the
patients could recover from the provincial health insurance
plan. This higher amount constituted extra-billing under the
CHA. Deductions began in May 1994, relating to fiscal year
1992–1993, and continued until extra-billing by physicians
was banned when changes to British Columbia’s Medicare
Protection Act came into effect in September 1995. In total,
$2,025,000 was deducted from British Columbia’s cash
contribution for extra-billing that occurred in the province
between 1992–1993 and 1995–1996. These deductions were
non-refundable, as were all subsequent deductions.
In January 1995, federal Minister of Health, Diane Marleau,
expressed concerns to her provincial and territorial colleagues
about the development of two-tiered health care and the
emergence of private clinics charging facility fees for medically
necessary services. As part of her communication with the
provinces and territories, Minister Marleau announced that
the provinces and territories would be given more than nine
months to eliminate these user charges, but that any province
that did not, would face financial penalties under the CHA.
Accordingly, beginning in November 1995, deductions were
applied to the cash contributions to Alberta, Manitoba, Nova
Scotia, and Newfoundland and Labrador for non-compliance
with the Federal Policy on Private Clinics.
14
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
From November 1995 to June 1996, total deductions of
$3,585,000 were made to Alberta’s cash contribution in
respect of facility fees charged at clinics providing surgical,
ophthalmological and abortion services. On October 1, 1996,
Alberta prohibited private surgical clinics from charging
patients a facility fee for medically necessary services for
which the physician fee was billed to the provincial health
insurance plan.
Similarly, due to facility fees allowed at an abortion clinic,
a total of $280,430 was deducted from Newfoundland and
Labrador’s cash contribution before these fees were eliminated,
effective January 1, 1998.
From November 1995 to December 1998, deductions from
Manitoba’s cash contribution amounted to $2,055,000, ending
with the confirmed elimination of user charges at surgical and
ophthalmology clinics, effective January 1, 1999. However,
during fiscal year 2001–2002, a monthly deduction (from
October 2001 to March 2002 inclusive) in the amount of
$50,033 was levied against Manitoba’s Canada Health and
Social Transfer (CHST) cash contribution on the basis of a
financial statement provided by the province showing that
actual amounts charged with respect to user charges for
insured services in fiscal years 1997–1998 and 1998–1999 were
greater than the deductions levied on the basis of estimates.
This brought total deductions levied against Manitoba
to $2,355,201.
With the closure of a private clinic in Halifax effective
November 27, 2003, Nova Scotia was deemed to be in
compliance with the Federal Policy on Private Clinics. Before it
closed, total deductions of $372,135 were made to Nova Scotia’s
CHST cash contribution for its failure to cover facility charges
to patients while paying the physician fee. A final deduction
of $5,463 was taken from the March 2005 Canada Health
Transfer (CHT) payment to Nova Scotia as a reconciliation
of deductions that had already been taken for 2002–2003.
A one-time positive adjustment in the amount of $8,121 was
made to Nova Scotia’s March 2006 CHT payment to reconcile
amounts actually charged in respect of extra-billing and user
charges with the penalties that had already been levied based
on provincial estimates reported for fiscal 2003–2004.
In January 2003, British Columbia provided a financial statement
in accordance with the Canada Health Act Extra-billing and
User Charges Information Regulations, indicating aggregate
amounts actually charged with respect to extra-billing and
user charges during fiscal year 2000–2001, totalling $4,610.
Accordingly, a deduction of $4,610 was made to the March 2003
CHST cash contribution.
CHAPTER 2: ADMINISTRATION AND COMPLIANCE
In 2004, British Columbia did not report to Health Canada
the amounts of extra-billing and user charges actually
charged during fiscal year 2001–2002, in accordance with
the requirements of the Extra-billing and User Charges
Information Regulations. As a result of reports that
British Columbia was investigating cases of user charges,
a $126,775 deduction was taken from British Columbia’s
March 2004 CHST payment, based on the amount
the Minister estimated to have been charged during
fiscal year 2001–2002.
Since 2005, $1,253,145 in cash transfer deductions have been
taken from British Columbia’s CHT payments in light of
patient charges reported by the province to Health Canada.
The deduction taken in 2012–2013 in respect of fiscal year
2010–2011 was estimated by the federal Minister of Health
and represents the aggregate of the amounts reported to Health
Canada by British Columbia and those reported publicly
as the result of an audit performed by the Medical Services
Commission of British Columbia. Deductions for each year
are detailed in a table following this passage.
A deduction of $1,100 was taken from the March 2005 CHT
payment to Newfoundland and Labrador as a result of patient
charges for a magnetic resonance imaging scan in a hospital
which occurred during 2002–2003. The March 2007 CHT
payment to Nova Scotia was reduced by $9,460 in respect of
extra-billing during fiscal year 2004–2005.
Since March 2011, deductions totalling $102,249 have been
taken from CHT payments to Newfoundland and Labrador for
extra-billing and user charges, based on charges reported by the
province to Health Canada. Since these charges resulted from
services provided by an opted-out dental surgeon who has since
left the province, Health Canada considers this matter resolved.
Since the passage of the CHA, from April 1984 to March 2013,
deductions totaling $10,112,447 have been taken from transfer
payments in respect of the extra-billing and user charges
provisions of the CHA. This amount excludes deductions
totaling $244,732,000 that were made between 1984 and 1987
and subsequently refunded to the provinces when extra-billing
and user charges were eliminated.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
15
CHAPTER 2: ADMINISTRATION AND COMPLIANCE
DEDUCTIONS AND REFUNDS TO CHST/CHT CASH CONTRIBUTIONS IN ACCORDANCE
WITH THE CANADA HEALTH ACT SINCE 1994 –1995 (IN DOLL ARS)
Province/
Territory
1994–1995 1995–1996 1996–1997 1997–1998 1998–1999 1999–2000 2000–2001 2001–2002 2002–2003 2003–2004 2004–2005
NL
0
46,000
96,000
128,000
53,000
(42,570)
0
0
0
0
1,100
PEI
0
0
0
0
0
0
0
0
0
0
0
NS
0
32,000
72,000
57,000
38,950
61,110
57,804
35,100
11,052
7,119
5,463
NB
0
0
0
0
0
0
0
0
0
0
0
QC
0
0
0
0
0
0
0
0
0
0
0
ON
0
0
0
0
0
0
0
0
0
0
0
MB
0
269,000
588,000
586,000
612,000
0
0
300,201
0
0
0
SK
0
0
0
0
0
0
0
0
0
0
0
AB
0
2,319,000
1,266,000
0
0
0
0
0
0
0
0
BC
1,982,000
43,000
0
0
0
0
0
0
4,610
126,775
72,464
YK
0
0
0
0
0
0
0
0
0
0
0
NWT
0
0
0
0
0
0
0
0
0
0
0
NU
0
0
0
0
0
0
0
0
0
0
0
1,982,000
2,709,000
2,022,000
771,000
703,950
18,540
57,804
335,301
15,662
133,894
79,027
Total
Understanding This Chart
• To date, most deductions have been made on the basis of statements of actual extra-billing and user charges, meaning they are made two years after the extra-billing
and user charges occurred.
• In instances where provinces and territories estimate anticipated amounts of extra-billing and user charges for the upcoming year, a deduction is taken in respect
of those charges in the fiscal year for which they are estimated.
• In addition to forming the basis for most deductions under the Act, the statements of actual extra-billing and user charges provide an opportunity to reconcile any
estimated charges with those that actually occurred. These reconciliations form the basis for further deductions or refunds to provincial and territorial cash transfers.
• Numbers in parentheses represent refunds to the province or territory.
16
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
CHAPTER 2: ADMINISTRATION AND COMPLIANCE
DEDUCTIONS AND REFUNDS TO CHST/CHT CASH CONTRIBUTIONS IN ACCORDANCE
WITH THE CANADA HEALTH ACT SINCE 1994 –1995 (IN DOLL ARS) (CONTINUED)
2005–2006 2006–2007 2007–2008 2008–2009 2009–2010 2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
Total
0
0
0
0
0
3,577
58,679
50,758
(10,765)
0
383,779
0
0
0
0
0
0
0
0
0
0
0
(8,121)
9,460
0
0
0
0
0
0
0
0
378,937
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2,355,201
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3,585,000
29,019
114,850
42,113
66,195
73,925
75,136
33,219
280,019
224,568
241,637
3,409,530
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
20,898
124,310
42,113
66,195
73,925
78,713
91,898
330,777
213,803
241,637
10,112,447
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
17
18
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
CHAPTER 3
PROVINCIAL AND TERRITORIAL
HEALTH CARE INSURANCE
PLANS IN 2014–2015
The following chapter presents the 13 provincial and territorial
health insurance plans that make up the Canadian publicly
funded health insurance system. The purpose of this chapter
is to demonstrate clearly and consistently the extent to which
provincial and territorial plans fulfilled the requirements
of the Canada Health Act program criteria and conditions
in 2014–2015.
The process for the Canada Health Act Annual Report
2014–2015 was launched late spring 2015 with bilateral
teleconferences with each jurisdiction. An updated User’s
Guide was also sent to the provinces and territories at that time.
Officials in the provincial, territorial and federal governments
have collaborated to produce the detailed plan overviews
contained in Chapter 3. The information that Health Canada
requested from the provincial and territorial departments of
health for the report consists of two components:
For the following chapter, provincial and territorial officials
were asked to provide a narrative description of their health
insurance plan. The descriptions follow the program criteria
areas of the Canada Health Act in order to illustrate how the
plans satisfy these criteria. This narrative format also allows
each jurisdiction to indicate how it met the Canada Health Act
requirement for the recognition of federal contributions that
support insured and extended health care services.
■■ a narrative description of the provincial or territorial health
care system relating to the criteria and conditions of the Act,
which can be found following this introduction; and
■■ statistical information related to insured health services.
The narrative component is used to help with the monitoring
and compliance of provincial and territorial health care plans
with respect to the requirements of the Act, while statistics help
to identify current and future trends in the Canadian health
care system. While all provinces and territories have submitted
detailed descriptive information on their health insurance plans,
Quebec chose not to submit supplemental statistical information
which is contained in the tables in this year’s report.
To help provinces and territories prepare their submissions
to the annual report, Health Canada provided them with the
document; Canada Health Act Annual Report 2014–2015:
A Guide for Updating Submissions (User’s Guide). The User’s
Guide is designed to help provinces and territories meet Health
Canada’s reporting requirements. Annual revisions to the
guide are based on Health Canada’s analysis of health plan
descriptions from previous annual reports and its assessment
of emerging issues relating to insured health services.
INSURANCE PLAN DESCRIPTIONS
PROVINCIAL AND TERRITORIAL
HEALTH CARE INSURANCE
PLAN STATISTICS
Over time, the section of the annual report containing the
statistical information submitted from the provinces and
territories has been simplified and streamlined based on
feedback received from provincial and territorial officials,
and based on reviews of data quality and availability. The
supplemental statistical information tables can be found at the
end of each provincial or territorial narrative, except for Quebec.
The purpose of the statistical tables is to place the administration and operation of the Canada Health Act in context and to
provide a national perspective on trends in the delivery and
funding of insured health services in Canada that are within
the scope of the Act.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
19
CHAPTER 3: PROVINCIAL AND TERRITORIAL HEALTH CARE INSURANCE PLANS IN 2014–2015
The statistical tables contain resource and cost data for
insured hospital, physician and surgical-dental services by
province and territory for five consecutive years ending on
March 31, 2015. All information was provided by provincial
and territorial officials.
Insured Hospital Services Provided to Residents in Another
Province or Territory: This sub-section presents out-ofprovince or out-of-territory insured hospital services that are
paid for by a person’s home jurisdiction when they travel to
other parts of Canada.
Although efforts are made to capture data on a consistent basis,
differences exist in the reporting on health care programs
and services between provincial and territorial governments.
Therefore, comparisons between jurisdictions are not made.
Provincial and territorial governments are responsible for
the quality and completeness of the data they provide.
Insured Hospital Services Provided Outside Canada:
This represents residents’ hospital costs incurred while
travelling outside of Canada that are paid for by their home
province or territory.
Organization of the Information
Information in the statistical tables is grouped according
to the nine subcategories described below.
Registered Persons: Registered persons are the number
of residents registered with the health care insurance plans
of each province or territory.
Insured Hospital Services Within Own Province or
Territory: Statistics in this sub-section relate to the provision
of insured hospital services to residents in each province or
territory, as well as to visitors from other regions of Canada.
20
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
Insured Physician Services Within Own Province or
Territory: Statistics in this sub-section relate to the provision
of insured physician services to residents in each province or
territory, as well as to visitors from other regions of Canada.
Insured Physician Services Provided to Residents in Another
Province or Territory: This sub-section reports on physician
services that are paid by a jurisdiction to other provinces or
territories for their visiting residents.
Insured Physician Services Provided Outside Canada:
This represents residents’ medical costs incurred while
travelling outside of Canada that are paid by their home
province or territory.
Insured Surgical-Dental Services Within Own Province or
Territory: The information in this subsection describes insured
surgical-dental services provided in each province or territory.
NEWFOUNDLAND AND LABRADOR
INTRODUCTION
The Department of Health and Community Services (the
Department) is responsible for setting the overall strategic
directions and priorities for the health and community services
system throughout Newfoundland and Labrador. In 2014, the
Department of Seniors, Wellness and Social Development was
created. As a result, the responsibility for the Healthy Living
Division and the Office of Aging and Seniors has moved to the
new department. This resulted in a slight change in the lines
of business for the Department of Health and Community
Services with the removal of the following divisions:
1) Health Promotion and Wellness; 2) Healthy Aging
and Seniors; and 3) Support to Community Agencies.
The Department works with stakeholders to develop and
enhance policies, legislation, provincial standards and strategies
to support individuals, families and communities to achieve
optimal health and well-being. The Department provides a lead
role in policy, planning, program development, and support
to the four regional health authorities. The Department also
works with stakeholders to ensure high quality, cost effective
and timely health services are available for all Newfoundlanders
and Labradorians.
The Department provides leadership, coordination, monitoring
and support to the regional health authorities who deliver the
majority of publicly funded health services in the province, as
well as other entities who deliver programs and services. This
ensures quality, efficiency and effectiveness in areas such as
the administration of health care facilities; access and clinical
efficiency; programs for seniors, persons with disabilities
and persons with mental health and addictions issues as well
as long-term care and community support services; health
professional education and training programs; the control,
possession, handling, keeping and sale of food and drugs;
the preservation and promotion of health; the prevention and
control of disease; and public health and the enforcement of
public health standards.
Budget 2014–2015 included an investment of nearly $3 billion
to help ensure better health, better care and better value for
Newfoundlanders and Labradorians. Investments were made
to increase access to diagnostic and treatment services for
children with autism and other conditions, increased dialysis
capacity, to provide vital programming in long term care and
community support services through the province, investments
in infrastructure and redevelopment of facilities.
In Newfoundland and Labrador, health services are provided
to over 500,000 residents by approximately 20,000 health care
providers, support staff and administrators.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
Health care insurance plans managed by the Department
of Health and Community Services include the Hospital
Insurance Plan and the Medical Care Plan (MCP). Both plans
are non-profit and publicly administered.
The Hospital Insurance Agreement Act is the legislation that
enables the Hospital Insurance Plan. The Act gives the
Minister of Health and Community Services the authority
to make regulations for providing insured services on
uniform terms and conditions to residents of the province
under the conditions specified in the Canada Health Act and
its regulations.
The Medical Care Insurance Act, 1999 requires the Minister to
administer a plan of medical care insurance for residents of
the province. It provides for the development of regulations to
ensure that the provisions of the statute meet the requirements
of the Canada Health Act as it relates to administering the MCP.
The MCP facilitates the delivery of comprehensive medical
care to all residents of the province by implementing policies,
procedures and systems that permit appropriate compensation
to providers for rendering insured professional services.
The MCP operates in accordance with the provisions of the
Medical Care Insurance Act, 1999 and regulations, and in
compliance with the Canada Health Act.
There were no substantive legislative amendments to the
Medical Care Insurance Act, 1999 or the Hospital Insurance
Agreement Act in 2014–2015.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
21
CHAPTER 3: NEWFOUNDLAND AND LABRADOR
1.2 Reporting Relationship
The Department is mandated with administering the Hospital
Insurance and Medical Care Plans. The Department reports
on these plans through the regular legislative processes,
e.g., Public Accounts and the Social Services Committees
of the House of Assembly.
The Government of Newfoundland and Labrador has
a provincial planning and reporting requirement for all
government departments, including the Department of
Health and Community Services. Under the Transparency and
Accountability Act, the Department of Health and Community
Services and the 12 entities that report to the Minister, including
regional health authorities (RHAs), produce a strategic plan once
every three years and report annually on performance. Plans and
reports are tabled in the House of Assembly and posted on the
Department’s website. http://www.assembly.nl.ca
The 2014–2015 Department of Health and Community Services
Annual Report will be tabled in the House of Assembly by the
end of September 30, 2015.
1.3 Audit of Accounts
Each year, the province’s Auditor General independently
examines provincial public accounts. MCP expenditures are
considered a part of the public accounts. While respecting
privacy and personal information, the Auditor General has full
and unrestricted access to code based MCP records.
The four RHAs are subject to financial statement audits,
reviews, and compliance audits. Financial statement audits
are performed by independent auditing firms that are selected
by the health authorities. Review engagements, compliance
audits and physician audits were carried out by personnel
from the Department under the authority of the Medical Care
Insurance Act, 1999. Physician records and professional medical
corporation records were reviewed to ensure that the records
supported the services billed and that the services are insured
under the MCP.
Beneficiary audits were performed by personnel from the
Department under the Medical Care Insurance Act, 1999.
Individual providers are randomly selected on a bi-weekly
basis for audit.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
The Hospital Insurance Agreement Act and the Hospital Insurance
Regulations, made thereunder, provide for insured hospital
services in Newfoundland and Labrador.
22
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
Insured hospital services are provided for in-patients and
out-patients in 15 hospitals, 22 community health centres
and 14 community clinics as well as numerous health and
community services clinics throughout the province. Insured
services include: accommodations and meals at the standard
ward level; nursing services; laboratory, radiology and
other diagnostic procedures; drugs, biological and related
preparations; medical and surgical supplies; operating room,
case room and anaesthetic facilities; rehabilitative services
(e.g., physiotherapy, occupational therapy, speech language
pathology and audiology); out-patient and emergency visits;
and day surgery.
The coverage policy for insured hospital services is linked
to the coverage policy for insured medical services. The
Department of Health and Community Services manages the
process of adding or de-listing a hospital service from the list
of insured services based on direction from the LieutenantGovernor in Council. There were no services added or de-listed
in 2014–2015.
2.2 Insured Physician Services
The enabling legislation for insured physician services is the
Medical Care Insurance Act, 1999 and the regulations made
thereunder, which include the:
■■ Medical Care Insurance Insured Services Regulations;
■■ Medical Care Insurance Beneficiaries and Inquiries
Regulations; and
■■ Physicians and Fee Regulations.
In 2014–2015 there were 1,210 physicians registered in
the province.
For purposes of the Act, the following services are covered:
■■ all services properly and adequately provided by physicians
to beneficiaries suffering from an illness requiring medical
treatment or advice;
■■ group immunizations or inoculations carried out by
physicians at the request of the appropriate authority; and
■■ diagnostic and therapeutic x-ray and laboratory services in
facilities approved by the appropriate authority that are not
provided under the Hospital Insurance Agreement Act and
regulations made under the Act.
Physicians can choose not to participate in the health care
insurance plan as outlined in section 12(1) of the Medical Care
Insurance Act, 1999, namely:
12(1) Where a physician providing insured services is not
a participating physician, and the physician provides an
insured service to a beneficiary, the physician is not subject
to this Act or the regulations relating to the provision of
CHAPTER 3: NEWFOUNDLAND AND LABRADOR
insured services to beneficiaries or the payment to be made
for the services except that he or she shall:
a) before providing the insured service, if he or she wishes
to reserve the right to charge the beneficiary for the
service an amount in excess of that payable by the
Minister under this Act, inform the beneficiary that
he or she is not a participating physician and that the
physician may so charge the beneficiary; and
b) provide the beneficiary to whom the physician has
provided the insured service with the information
required by the Minister to enable payment to be made
under this Act to the beneficiary in respect of the
insured service.
(2) Where a physician who is not a participating physician
provides insured services through a professional medical
corporation, the professional medical corporation is not,
in relation to those services, subject to this Act or the
regulations relating to the provision of insured services
to beneficiaries or the payment to be made for the
services and the professional medical corporation and the
physician providing the insured services shall comply with
subsection (1).
As of March 31, 2015 there were no physicians who had opted
out of the Medical Care Plan (MCP).
Lieutenant-Governor in Council approval is required to add
to or to de-insure a physician service from the list of insured
services. This process is managed by the Department in
consultation with various stakeholders.
2.3 Insured Surgical-Dental Services
The provincial Surgical-Dental Program is a component of the
MCP. Surgical-dental treatments provided to a beneficiary and
carried out in a hospital by a licensed oral surgeon or dentist are
covered by MCP if the treatment is specified in the SurgicalDental Services Schedule.
Dentists may opt out of the MCP. These dentists must advise
the patient of their opted-out status, state the fees expected,
and provide the patient with a written record of services and
fees charged. As of March 31, 2015, there were no opted-out
dentists. There was no extra-billing in 2014–2015.
Because the Surgical-Dental Program is a component of the
MCP, management of the program is linked to the MCP
process regarding changes to the list of insured services.
Addition of a surgical-dental service to the list of insured
services must be approved by the Minister.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Hospital services not covered by MCP include: preferred
accommodation at the patient’s request; cosmetic surgery
and other services deemed to be medically unnecessary;
ambulance or other patient transportation before admission
or upon discharge; private duty nursing arranged by the
patient; non-medically required x-rays or other services for
employment or insurance purposes; drugs (except anti-rejection
and AZT drugs) and appliances issued for use after discharge
from hospital; bedside telephones, radios or television sets
for personal, non-teaching use; fibreglass splints; services
covered by the Workplace Health, Safety and Compensation
Commission or by other federal or provincial legislation; and
services relating to therapeutic abortions performed in nonaccredited facilities or facilities not approved by the College
of Physicians and Surgeons of Newfoundland and Labrador.
The use of the hospital setting for any services deemed
not insured by the MCP are also uninsured under the
Hospital Insurance Plan. For purposes of the Medical Care
Insurance Act, 1999, the following is a list of non-insured
physician services:
■■ any advice given by a physician to a beneficiary by telephone;
■■ the dispensing by a physician of medicines, drugs or medical
appliances and the giving or writing of medical prescriptions;
■■ the preparation by a physician of records, reports or
certificates for, or on behalf of, or any communication to,
or relating to, a beneficiary;
■■ any services rendered by a physician to the spouse and
children of the physician;
■■ any service to which a beneficiary is entitled under an Act
of the Parliament of Canada, an Act of the Province of
Newfoundland and Labrador, an Act of the legislature of
any province of Canada, or any law of a country or part of
a country;
■■ the time taken or expenses incurred in travelling to consult
a beneficiary;
■■ ambulance service and other forms of patient transportation;
■■ acupuncture and all procedures and services related to
acupuncture, excluding an initial assessment specifically
related to diagnosing the illness proposed to be treated
by acupuncture;
■■ examinations not necessitated by illness or at the request
of a third party except as specified by the Department;
■■ plastic or other surgery for purely cosmetic purposes,
unless medically indicated;
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
23
CHAPTER 3: NEWFOUNDLAND AND LABRADOR
■■ laser treatment of telangiectasia;
3.0UNIVERSALITY
■■ visits to optometrists, general practitioners and ophthal­
3.1Eligibility
■■ testimony in a court;
mologists solely for determining whether new or
replacement glasses or contact lenses are required;
■■ the fees of a dentist, oral surgeon or general practitioner
for routine dental extractions performed in hospital;
■■ fluoride dental treatment for children under four years of age;
■■ excision of xanthelasma;
■■ circumcision of newborns;
■■ hypnotherapy;
■■ medical examination for drivers;
■■ alcohol/drug treatment outside Canada;
■■ consultation required by hospital regulation;
■■ therapeutic abortions performed in the province at a facility
not approved by the College of Physicians and Surgeons of
Newfoundland and Labrador;
■■ sex reassignment surgery, when not recommended by the
Clarke Institute of Psychiatry;
■■ in vitro fertilization and OSST (ovarian stimulation and
sperm transfer);
■■ reversal of previous sterilization procedure;
■■ surgical, diagnostic or therapeutic procedures provided in
facilities as of January 1998 other than those covered under
the Hospital Insurance Agreement Act or approved by the
appropriate authority under paragraph 3(d) of the Medical
Care Insurance Insured Services Regulations; and
■■ other services not within the ambit of section 3 of the
Medical Care Insurance Insured Services Regulations.
The majority of diagnostic services (e.g., laboratory services and
x-ray) are performed within public facilities in the province.
Hospital policy concerning access ensures that third parties
are not given priority access.
Medical goods and services that are implanted and associated
with an insured service are provided free of charge to the
patient and are consistent with national standards of practice.
Patients retain the right to financially upgrade standard medical
goods or services. Standards for medical goods are developed
by the hospitals providing those services in consultation with
service providers.
The Medical Care Insurance Act, 1999 provides the LieutenantGovernor in Council with the authority to make regulations
prescribing which services are or are not insured services for
the purpose of the Act.
24
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
There were 533,156 people registered with the Medical Care
Plan as of March 31, 2015. Residents of Newfoundland and
Labrador are eligible for coverage under the Medical Care
Insurance Act, 1999 and the Hospital Insurance Agreement Act. The
Medical Care Insurance Act, 1999 defines a “resident” as a person
lawfully entitled to be or to remain in Canada, who makes his or
her home and is ordinarily present in the province, but does not
include tourists, transients or visitors to the province.
The Medical Care Insurance Beneficiaries and Inquiries
Regulations identify those residents eligible to receive coverage
under the plans. The Medical Care Plan (MCP) has established
rules to ensure that the regulations are applied consistently and
fairly in processing applications for coverage. MCP applies the
standard that persons moving to Newfoundland and Labrador
from another province become eligible on the first day of the
third month following the month of their arrival.
Persons not eligible for coverage under the plans include:
students and their dependants already covered by another
province or territory; dependents of residents if covered by
another province or territory; certified refugees and refugee
claimants and their dependents; foreign workers with
employment authorizations and their dependants who do
not meet the established criteria; tourists, transients, visitors
and their dependents; Canadian Forces personnel; inmates
of federal prisons; and armed forces personnel from other
countries who are stationed in the province. If the status
of these individuals changes, they must meet the criteria
for eligibility as noted above in order to become eligible.
3.2 Other Categories of Individuals
Foreign workers, international students, clergy and dependants
of North Atlantic Treaty Organization (NATO) personnel
are eligible for benefits. Holders of Minister’s permits are also
eligible, subject to MCP approval.
4.0PORTABILITY
4.1 Minimum Waiting Period
Insured persons moving to Newfoundland and Labrador from
other provinces or territories are entitled to coverage on the first
day of the third month following the month of arrival.
Persons arriving from outside Canada to establish residence are
entitled to coverage on the day of arrival. The same applies to
discharged members of the Canadian Forces, and individuals
CHAPTER 3: NEWFOUNDLAND AND LABRADOR
released from federal penitentiaries. For coverage to be effective;
however, registration is required under the Medical Care Plan
(MCP). Immediate coverage is provided to persons from outside
Canada authorized to work in the province for one year or more.
4.2 Coverage During Temporary Absences
in Canada
■■ Persons leaving the province for employment purposes
may receive a certificate for coverage up to 12 months.
Verification of employment may be required.
■■ Persons must not establish residence in another province,
territory or country while maintaining coverage under the
Newfoundland MCP.
■■ For out-of-province trips of 30 days or less, an out-of-
province coverage certificate is not required, but will be
issued upon request.
Newfoundland and Labrador is a party to the Interprovincial
Agreement on Eligibility and Portability regarding matters
pertaining to portability of insured services in Canada.
■■ For out-of-province trips lasting more than 30 days, a
Sections 12 and 13 of the Hospital Insurance Regulations
define portability of hospital coverage during absences both
within and outside Canada. The eligibility policy for insured
hospital services is linked to the eligibility policy for insured
physician services.
Failure to request out-of-province coverage or failure to abide
by the residency rules may result in the resident having to pay
for medical or hospital costs incurred outside the province.
Coverage is provided to residents during temporary absences
within Canada. The Government of Newfoundland and
Labrador has entered into formal agreements (e.g., the Hospital
Reciprocal Billing Agreement) with other provinces and
territories for the reciprocal billing of insured hospital services.
In-patient costs are paid at standard rates approved by the
host province or territory. In-patient, high-cost procedures
and out-patient services are payable based on national
rates agreed to by provincial and territorial health plans
through the Interprovincial Health Insurance Agreements
Coordinating Committee.
Medical services incurred in all provinces (except Quebec) or
territories, are paid through the Medical Reciprocal Billing
Agreement at host province or territory rates. Claims for
medical services received in Quebec are submitted by the
patient to the MCP for payment at host province rates.
In order to qualify for out-of-province coverage, a beneficiary
must comply with the legislation and MCP rules regarding
residency in Newfoundland and Labrador. A resident must
reside in the province at least four consecutive months in each
12-month period to qualify as a beneficiary. Generally, the rules
regarding medical and hospital care coverage during absences
include the following:
■■ Before leaving the province for extended periods, a resident
must contact the MCP to obtain an out-of-province
coverage certificate.
■■ Beneficiaries leaving for vacation purposes may receive
an initial out-of-province coverage certificate of up to
12 months. Upon return, beneficiaries are required to
reside in the province for a minimum four consecutive
months. Thereafter, certificates will only be issued for
up to eight months of coverage.
■■ Students leaving the province may receive a certificate,
certificate is required as proof of a resident’s ability to pay
for services while outside the province.
Insured residents moving permanently to other parts of Canada
are covered up to and including the last day of the second
month following the month of departure.
4.3 Coverage During Temporary Absences
Outside Canada
The province provides coverage to residents during temporary
absences outside Canada. Out-of-country insured hospital
in-patient and out-patient services are covered for emergencies,
sudden illness, and elective procedures at established rates.
Hospital services are considered under the Plan when the
insured services are provided by a recognized facility (licensed
or approved by the appropriate authority within the state or
country in which the facility is located) outside Canada. The
maximum amount payable by the government’s hospitalization
plan for out-of-country in-patient hospital care is $350 per day,
if the insured services are provided by a community or regional
hospital. Where insured services are provided by a tertiary
care hospital (a highly specialized facility), the approved rate
is $465 per day. The approved rate for out-patient services
is $62 per visit and hemodialysis is $330 per treatment.
The approved rates are paid in Canadian funds.
Physician services are covered for emergencies or sudden illness,
and are also insured for elective services not available in the
province or within Canada. Emergency Physician services are
paid at the same rate as would be paid in Newfoundland and
Labrador for the same service. If the elective services are not
available in Newfoundland and Labrador, they are usually paid
at Ontario rates, or at rates that apply in the province where
they are available.
Coverage is immediately discontinued when residents move
permanently to other countries.
renewable each year, provided they submit proof of full-time
enrolment in a recognized educational institution located
outside the province.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
25
CHAPTER 3: NEWFOUNDLAND AND LABRADOR
4.4 Prior Approval Requirement
Prior approval is not required for medically necessary insured
services provided by accredited hospitals or licensed physicians
in the other provinces and territories. However, physicians may
seek advice on coverage from the MCP so that patients may be
made aware of any financial implications.
Prior approval is mandatory in order to receive funding at host
country rates if a resident of the province has to seek specialized
hospital care outside the country because the insured service is
not available in Canada. The referring physicians must contact
the Department for prior approval. If prior approval is granted,
the provincial health insurance plan will pay the costs of insured
services necessary for the patient’s care. Prior approval is not
granted for out-of-country treatment or elective services if the
service is available in the province or elsewhere within Canada.
If the services are not available in Newfoundland and Labrador,
they are usually paid at Ontario rates, or at rates that apply in
the province where they are available.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
Access to insured health services in Newfoundland and
Labrador is provided on uniform terms and conditions. There
are no co-insurance charges for insured hospital services and
there is no extra-billing by physicians in the province.
The Department of Health and Community Services
works closely with post-secondary educational institutions
within the province to maintain an appropriate supply of
health professionals. The province also works with external
organizations for health professionals not trained in this
province. Targeted recruitment incentives are in place to
attract health professionals. Several programs have been
established to provide targeted sign-on bonuses, bursaries,
opportunities for upgrading, and other incentives for a wide
variety of health occupations.
Newfoundland and Labrador continues to be a national
leader in wait time improvements. The key drivers of these
improvements are the implementation of actions under three
provincial strategies: the Provincial Emergency Department
Wait Time Strategy; the Provincial Hip and Knee Joint
Replacement Wait Time Strategy, which included increased
Provincial Government funding to complete additional joint
replacement surgeries; and the Provincial Endoscopy Wait
Time Strategy.
Newfoundlanders and Labradorians continue to have
some of the shortest benchmark wait times in the country.
Newfoundland and Labrador is ranked as the best in Canada
in the wait times for hip and knee replacement and cataract
26
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
surgery. Furthermore, according to the Canadian Institute
for Health Information annual report Wait Times for
Priority Procedures in Canada, Newfoundland and Labrador
was the only province to achieve 9 out of 10 (90 percent)
benchmark results compared to the rest of Canada in which
8 out 10 (80 percent) patients are receiving access to priority
benchmark procedures.
Through the actions of the joint replacement strategy,
Newfoundland and Labrador continues to be a national leader
with the shortest wait times in the country for hip and knee
replacement surgery. Since Newfoundland and Labrador’s
strategy was released (2012), we have seen a 34 percent increase
(from 60 to 94 percent) in the number of knee replacement
surgeries being completed within the 182 day benchmark.
During the fourth quarter of 2014–2015 (January 1 to
March 31, 2015), wait time reports demonstrated that,
on average, 94 percent of residents of Newfoundland and
Labrador received timely access to benchmark procedures
within the recommended targets. The national benchmark
is 90 percent.
We are improving Emergency Departments to ensure there
are shorter wait times and patients are assessed and treated
in a timely manner. Through the actions of the Provincial
Emergency Department Wait Time Strategy, external reviews
were carried out at four additional Emergency Departments
in the province. We have now completed external reviews in
10 of our 13 Category A emergency departments. Through these
reviews, a variety of initiatives were undertaken to improve
wait times, including Nurse First triage, alignment of staffing
allocations to meet peak patient demand; implementation of
fast track units to treat low acuity patients, implementation of
a Rapid Assessment Zone (RAZ) at Health Sciences Center
to expedite assessment and treatment of urgent (Canadian
Triage Acuity Scale Level 3) patients, and use of the provincial
HealthLine to carry out follow-up contact with patients who
left without being seen. As a result of this work, we are seeing
reductions in the time for physician initial assessment (PIA) and
the number of patients leaving without being seen (LWBS).
Government invested $2 million in Budget 2014 to address
endoscopy wait times and wait lists. As a result of our
partnership with Canadian Association of Gastroenterologists
(CAG) and the leadership of the physicians and administration
in the four regional health authorities (RHAs), the province
was and is still the first and only province in Canada in which
100 percent (12/12) of endoscopy suites are enrolled in the
CAG Quality Program and have completed the Canadian
Global Rating Scale. Additionally, the department continued
its work with the Eastern Regional Health Authority in
partnership with CAG to implement the Skills Enhancement
in Endoscopy (SEE) program in the province in 2014. As a
result of this work, Eastern Regional Health Authority has
become a designated training site for the SEE program.
CHAPTER 3: NEWFOUNDLAND AND LABRADOR
5.2 Physician Compensation
The legislation governing payments to physicians and
dentists for insured services is the Medical Care Insurance
Act, 1999. Compensation agreements are negotiated between
the provincial government and the Newfoundland and
Labrador Medical Association (NLMA), on behalf of all
physicians. Representatives from the RHAs play a role in
this process. A Memorandum of Agreement was reached
with the NLMA in December 2010, which increased overall
physician compensation by approximately 26 percent. The
Agreement expired on September 30, 2013 but remains
in effect until such time as a new agreement is negotiated.
Physicians are paid via fee-for-service, salary or alternate
payment plan (APP) with an increasing interest in APPs
as a method of remuneration by physicians.
5.3 Payments to Hospitals
The Department is responsible for funding RHAs for ongoing
operations and capital acquisitions. Funding for insured
services is provided to the RHAs as an annual global budget.
Payments are made in accordance with the Hospital Insurance
Agreement Act and the Regional Health Authorities Act. As
part of their accountability to the government, the health
authorities are required to meet the Department’s annual
reporting requirements, which include audited financial
statements and other financial and statistical information.
The global budgeting process devolves the budget allocation
authority, responsibility, and accountability to all appointed
boards in the discharge of their mandates.
Throughout the fiscal year, the RHAs forwarded additional
funding requests to the Department for any changes in
program areas or increased workload volume. These requests
were reviewed and, when approved by the Department, funded
at the end of each fiscal year. Any adjustments to the annual
funding level, such as for additional approved positions or
program changes, were funded based on the implementation
date of such increases and the cash flow requirements.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
Funding provided by the federal government through the
Canada Health Transfer (CHT) and the Canada Social
Transfer (CST) has been recognized and reported by the
Government of Newfoundland and Labrador in the annual
provincial budget, through press releases, government websites
and various other documents. For fiscal year 2014–2015, these
documents include:
■■ the 2014–2015 Public Accounts;
■■ the Estimates 2014–2015; and
■■ the Budget Speech 2014–2015.
The Public Accounts and Estimates, tabled by the Government
in the House of Assembly, are publicly available and are shared
with Health Canada for information purposes.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
27
CHAPTER 3: NEWFOUNDLAND AND LABRADOR
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
523,508
527,714
530,521
532,177
533,156
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#).
5. Payments to private for-profit facilities
for insured health services ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
51
51
51
51
51
1,028,697,016
1,088,392,487
1,097,535,388
1,100,291,277
1,131,546,830
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1
1
1
1
1
660,625
697,375
845,280
916,696
914,135
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1,632
1,648
1,844
1,574
1,773
21,096,749
17,507,684
19,988,002
20,969,617
22,423,411
23,156
23,482
27,681
22,429
26,671
7,214,089
7,216,918
8,827,387
8,109,628
9,147,633
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
28
CANADA HEALTH ACT
97
126
108
127
141
318,203
224,822
139,270
451,834
207,198
445
475
410
445
570
209,257
91,089
96,116
105,448
71,574
ANNUAL REPORT 2014–2015
CHAPTER 3: NEWFOUNDLAND AND LABRADOR
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1,096
1,115
1,155
1,183
1,210
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of not participating physicians (#).
0
0
0
0
0
not available
not available
not available
not available
not available
216,931,000
218,561,000
236,529,000
251,281,302
294,572,803
14.Number of participating physicians (#).1
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY 2
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
155,000
154,000
114,000
114,000
106,000
6,665,000
6,627,000
6,762,000
6,954,000
6,836,000
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
3,600
3,400
3,400
3,300
3,600
202,000
237,000
231,000
266,000
223,000
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
29
25
25
26
19
1,093
2,222
2,880
1,585
1,709
158,000
329,000
455,780
203,610
279,350
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
1. Excludes inactive physicians.Total salaried and fee-for-service.
2. Numbers are rounded to the nearest thousand.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
29
30
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
PRINCE EDWARD ISLAND
INTRODUCTION
In Prince Edward Island (PEI) the Department of Health and
Wellness is responsible for providing policy, strategic, and fiscal
leadership for the healthcare system.
The Health Services Act provides the regulatory and administrative
frameworks for improvements to the healthcare system in
PEI by:
■■ mandating the creation of a provincial health plan;
■■ establishing mechanisms to improve patient safety and
support quality improvement processes; and
■■ creating a Crown corporation (Health PEI) to oversee the
delivery of operational healthcare services.
Within this governance structure Health PEI has the
responsibility to:
■■ provide, or provide for the delivery of, health services;
■■ operate and manage health facilities;
■■ manage the financial, human and other resources necessary
to provide health services and operate health facilities; and
■■ perform such other duties as the Minister may direct.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
The Hospital Services Insurance Plan, under the authority of the
Minister of Health and Wellness, is the vehicle for delivering
hospital care insurance in Prince Edward Island (PEI). The
enabling legislation is the Hospital and Diagnostic Services
Insurance Act (1988). The Medical Services Insurance Plan
provides for insured physician services under the authority of the
Health Services Payment Act (1988). Together, the Plans insure
services as defined under section 2 of the Canada Health Act.
The Department of Health and Wellness is responsible
for providing policy, strategic and fiscal leadership for the
healthcare system, while Health PEI is responsible for service
delivery and the operation of hospitals, health centres, manors
and mental health facilities. Health PEI is responsible for the
hiring of physicians, while the Public Service Commission
of PEI hires nurse practitioners, nurses and all other health
related workers.
1.2 Reporting Relationship
An annual report is submitted by the Department to the
Minister responsible who tables it in the Legislative Assembly.
The report provides information about the operating principles
of the Department and its legislative responsibilities, as
well as an overview and description of the operations of the
departmental divisions and statistical highlights for the year.
Health PEI prepares an annual business plan which functions
as a formal agreement between Health PEI and the Minister
responsible, and documents accomplishments to be achieved
over the coming fiscal year.
1.3 Audit of Accounts
The provincial Auditor General conducts annual audits of the
public accounts of PEI. The public accounts of the province
include the financial activities, revenues and expenditures of the
Department of Health and Wellness.
The provincial Auditor General, through the Audit Act, has the
discretion to conduct further audit reviews on a comprehensive
or program specific basis.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
31
CHAPTER 3: PRINCE EDWARD ISLAND
2.0COMPREHENSIVENESS
they are required to inform the Minister thereof and the total
charge is made to the patient for the service rendered.
2.1 Insured Hospital Services
As of March 31, 2015, no physicians had opted out of the
Medical Services Insurance Plan.
Insured hospital services are provided under the Hospital and
Diagnostic Services Insurance Act (1988). The accompanying
regulations define the insured in-patient and out-patient
hospital services available at no charge to a person who is
eligible. Insured hospital services include, but are not limited
to: necessary nursing services; laboratory, radiological and other
diagnostic procedures; accommodations and meals at a standard
ward rate; formulary drugs, biologicals and related preparations
prescribed by an attending physician and administered in
hospital; operating room, case room and anaesthetic facilities;
routine surgical supplies; and radiotherapy and physiotherapy
services performed in hospital.
Any basic health services rendered by physicians that are
medically required are covered by the Medical Services
Insurance Plan. These include most physicians’ services in
the office, at the hospital or in the patient’s home; medically
necessary surgical services, including the services of anaesthetists
and surgical assistants where necessary; obstetrical services,
including pre-natal and post-natal care, newborn care or any
complications of pregnancy such as miscarriage or caesarean
section; certain oral surgery procedures performed by an oral
surgeon when it is medically required, with prior approval that
they be performed in a hospital; sterilization procedures, both
female and male; treatment of fractures and dislocations; and
certain insured specialist services, when properly referred by
an attending physician.
The process to add a new hospital service to the list of insured
services involves extensive consultation and negotiation
between the Department, Health PEI and key stakeholders.
The process involves the development of a business plan which,
when approved by the Minister, would be taken to Treasury
Board for funding approval. Executive Council (Cabinet) has
the final authority in adding new services.
2.2 Insured Physician Services
The enabling legislation that provides for insured physician
services is the Health Services Payment Act (1988).
Insured physician services are provided by medical practitioners
licensed by the College of Physicians and Surgeons. The total
number of practicing practitioners who billed the Medical
Services Insurance Plan as of March 31, 2015 was 331.
This includes all physicians (complement, locums, visiting
specialists, and other non-complement physicians). Prior to
2012–2013, Prince Edward Island (PEI) reported complement
physicians only.
Under section 10 of the Health Services Payment Act, a
physician or practitioner who is not a participant in the
Medical Services Insurance Plan is not eligible to bill the Plan
for services rendered. When a non-participating physician
provides a medically required service, section 10(2) requires
that physicians advise patients that they are non-participating
physicians or practitioners and provide the patient with
sufficient information to enable recovery of the cost of services
from the Minister of Health and Wellness. Under section 10.1
of the Health Services Payment Act, a participating physician
or practitioner may determine, subject to and in accordance
with the regulations and in respect of a particular patient or a
particular basic health service, to collect fees outside the Plan
or selectively opt out of the Plan. Before the service is rendered,
patients must be informed that they will be billed directly for
the service. Where practitioners have made that determination,
32
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
The process to add a physician service to the list of insured services
involves negotiation between the Department, Health PEI and
the Medical Society. The process involves development of a
business plan which, when approved by the Minister, would be
taken to Treasury Board for funding approval. Insured physician
services may also be added or deleted as part of the negotiation of
a new Master Agreement with physicians (Section 5.2). Cabinet
has the final authority in adding new services.
2.3 Insured Surgical-Dental Services
Dental services are not insured under the Medical Services
Insurance Plan. Only oral maxillofacial surgeons are paid
through the Plan. There are currently two surgeons in that
category. Surgical-dental procedures included as basic health
services in the Tariff of Fees are covered only when the
patient’s medical condition requires that they be done in
hospital or in an office with prior approval, as confirmed by
the attending physician.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Services not covered by the Hospital Services Insurance
Plan include:
■■ services that persons are eligible for under other provincial
or federal legislation;
■■ mileage or travel, unless approved by Health PEI;
■■ telephone consultation except by internists, palliative care
physicians, paediatricians, out-of-province specialists, and
orthopaedic surgeons, provided the patient was not seen by
that physician within 3 days of the telephone consult;
CHAPTER 3: PRINCE EDWARD ISLAND
■■ examinations required in connection with employment,
insurance, education, etc.;
■■ group examinations, immunizations or inoculations, unless
prior approval is received from Health PEI;
■■ preparation of records, reports, certificates or communications,
except a certificate of committal to a psychiatric, drug or
alcoholism facility;
■■ testimony in court;
■■ travel clinic and expenses;
■■ surgery for cosmetic purposes unless medically required;
■■ dental services other than those procedures included as basic
health services;
■■ dressings, drugs, vaccines, biologicals and related materials;
■■ eyeglasses and special appliances;
■■ chiropractic, podiatry, optometry, chiropody, osteopathy,
naturopathy, and similar treatments;
■■ physiotherapy, psychology, and acupuncture except when
provided in hospital;
■■ reversal of sterilization procedures;
■■ in vitro fertilization;
■■ services performed by another person when the supervising
physician is not present or not available;
■■ services rendered by a physician to members of the
physician’s own household, unless approval is obtained
from Health PEI; and
■■ any other services that the Department may, upon the
recommendation of the negotiation process between the
Department, Health PEI and the Medical Society, declare
non-insured.
Hospital services not covered by the Hospital Services Insurance
Plan include private or special duty nursing at the patient’s or
family’s request; preferred accommodation at the patient’s request;
hospital services rendered in connection with surgery purely for
cosmetic reasons; personal conveniences, such as telephones and
televisions; drugs, biologicals and prosthetic and orthotic appliances for use after discharge from hospital; and dental extractions,
except in cases where the patient must be admitted to hospital for
medical reasons with prior approval of Health PEI.
The process to de-insure services covered by the Medical
Services Insurance Plan is done in collaboration with the
Medical Society, Health PEI and the Department. No services
were de-insured during the 2014–2015 fiscal year.
All PEI residents have equal access to services. Third parties
such as private insurers or the Workers’ Compensation Board
of PEI do not receive priority access to services through
additional payment.
PEI has no formal process to monitor compliance; however,
feedback from physicians, hospital administrators, medical
professionals and staff allows the Department and Health PEI
to monitor usage and service concerns.
3.0UNIVERSALITY
3.1Eligibility
The Health Services Payment Act and Regulations, section 3,
define eligibility for the Medical Services Insurance Plan. This
Plan is designed to provide coverage for eligible Prince Edward
Island (PEI) residents. A resident is anyone legally entitled
to remain in Canada and who makes his or her home and is
ordinarily present on an annual basis for at least six months
plus a day, in PEI.
All new residents must register with the Department in order to
become eligible. Persons who establish permanent residence in
PEI from elsewhere in Canada will become eligible for insured
hospital and medical services on the first day of the third month
following the month of arrival.
Residents who are ineligible for insured hospital and medical
services coverage in PEI are those who are eligible for certain
services under other federal or provincial government programs,
such as members of the Canadian Forces, inmates of federal
penitentiaries, and clients of Workers’ Compensation or the
Department of Veterans Affairs’ programs.
Ineligible residents may become eligible in certain
circumstances. For example, members of the Canadian Forces
become eligible on discharge or completion of rehabilitative
leave. Penitentiary inmates become eligible upon release. In
such cases, the province where the individual in question was
stationed at the time of discharge or release, or release from
rehabilitative leave, would provide initial coverage during the
customary waiting period of up to three months. Parolees
from penitentiaries will be treated in the same manner as
discharged prisoners.
New or returning residents must apply for health coverage
by completing a registration application from HealthPEI.
The application is reviewed to ensure that all necessary
information is provided. A health card is issued and sent to
the resident within two weeks. Renewal of coverage takes place
every five years and residents are notified by mail six weeks
before renewal.
The number of residents registered with the Medical Services
Insurance Plan in PEI as of March 31, 2015, was 146,170.
3.2 Other Categories of Individuals
Foreign students, tourists, transients or visitors to PEI do
not qualify as residents of the province and are, therefore,
not eligible for hospital and medical insurance benefits.
Temporary workers, refugees and Minister’s Permit holders
are not eligible for hospital and medical insurance benefits.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
33
CHAPTER 3: PRINCE EDWARD ISLAND
4.0PORTABILITY
4.4 Prior Approval Requirement
4.1 Minimum Waiting Period
Insured persons who move to Prince Edward Island (PEI) are
eligible for health insurance on the first day of the third month
following the month of arrival in the province.
4.2 Coverage During Temporary Absences
in Canada
Residents absent each year for any reasons must reside in PEI
for at least six months plus a day each year in order to be eligible
for sudden illness and emergency services while absent from
the province, as allowed under section 11 of the Health Services
Payment Act. A person, including a student, who is temporarily
absent from the province for up to 182 days in a 12 month
period must notify Health PEI before leaving.
PEI participates in the Hospital Reciprocal Billing Agreement
and the Medical Reciprocal Billing Agreement along with
other jurisdictions across Canada.
4.3 Coverage During Temporary Absences
Outside Canada
The Health Services Payment Act is the enabling legislation
that defines portability of health insurance during temporary
absences outside Canada, as allowed under section 11.
Persons must reside in PEI for at least six months plus a
day each year in order to be eligible for sudden illness and
emergency services while absent from the province, as allowed
under section 11 of the Health Services Payment Act.
Insured residents may be temporarily out of the country for up
to a 12 month period in some circumstances.
Students attending a recognized learning institution in another
country must provide proof of enrolment from the educational
institution on an annual basis. Students must notify Health
PEI upon returning from outside the country.
For PEI residents leaving the country for work purposes for
longer than one year, coverage ends the day the person leaves.
For Island residents travelling outside Canada, coverage for
emergency or sudden illness will be provided at PEI rates only,
in Canadian currency. Residents are responsible for paying the
difference between the full amount charged and the amount
paid by the Department.
34
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
Prior approval is required from Health PEI before receiving
non-emergency, out-of-province medical or hospital services.
Island residents seeking such required services may apply for
prior approval through a PEI physician. Full coverage may be
provided for (PEI insured) non-emergency or elective services,
provided the physician completes an application to Health PEI.
Prior approval is required from the Medical Director of Health
PEI to receive out-of-country hospital or medical services not
available in Canada.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
Both of Prince Edward Island’s (PEI) hospital and medical
services insurance plans provide services on uniform terms
and conditions on a basis that does not impede or preclude
reasonable access to those services by insured persons.
PEI has a publicly administered and funded health system that
guarantees universal access to medically necessary hospital and
physician services as required by the Canada Health Act.
PEI recognizes that the health system must constantly adapt
and expand to meet the needs of our citizens. Several examples
of initiatives from the 2014–2015 fiscal year include:
■■ PEI opened a new provincial palliative care centre which
provides patients with more care options and their loved
ones the opportunity to be involved in care.
■■ Investments were made to expand the newborn screening
program, doubling the number of conditions and blood
disorders covered. The program also will provide a full range
of services beyond screening, such as arranging follow-up
appointments, clinical visits and referral to specialists for
patients who test positive for a condition.
■■ PEI implemented an Out-of-Province Travel Support
Program to provide assistance to eligible Island residents
for travel on Maritime Bus to approved health care services
within the Maritime Provinces.
■■ A new addictions transition unit opened as part of
Government’s action plan to enhance addiction services
for Islanders.
■■ Significant investments were made to increase and enhance
services to children with complex needs. Services to be
enhanced include pediatric occupational and physiotherapy,
orthoptics, preschool autism assessments, and speech
language pathology and audiology.
CHAPTER 3: PRINCE EDWARD ISLAND
As PEI is primarily a rural province where a large segment of
the population resides outside the main service centres, local
access to health services, including acute services delivered
through community hospitals and health centres, is important
to small communities. PEI continues to expand health
infrastructure necessary to support health service delivery
in rural communities.
5.2 Physician Compensation
A collective bargaining process is used to negotiate physician
compensation. Bargaining teams are appointed by both
physicians and the government to represent their interests
in the process. The current five-year Physician Master
Agreement between the PEI Medical Society, on behalf of
Island physicians, the Department of Health and Wellness,
and Health PEI is effective April 1, 2010 to March 31, 2015.
Negotiations for the new Master Agreement will begin in the
fall of 2015.
The legislation governing payments to physicians and dentists
for insured services is the Health Services Payment Act.
Many physicians continue to work on a fee-for-service basis;
however, alternate payment plans have been developed and
some physicians receive salary, contract and sessional payments.
Alternate payment modalities are expanding and seem to be
the preference for new graduates. Currently, 63 percent of
PEI’s physicians (excluding locums and visiting specialists) are
compensated under an alternate payment method (non-fee-forservice) as their primary means of remuneration.
5.3 Payments to Hospitals
Payments (advances) to provincial hospitals and community
hospitals for hospital services are approved for disbursement
by the Department in line with cash requirements and are
subject to approved budget levels.
The usual funding method includes using a global budget
adjusted annually to take into consideration increased costs
related to such items as labour agreements, drugs, medical
supplies and facility operations.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
The Government of Prince Edward Island strives to recognize
the federal contributions provided through the Canada Health
Transfer whenever appropriate. Over the past year, this has
included reference in public documents such as the Province of
PEI 2014–2015 Annual Budget and in the 2014–2015 Public
Accounts, which both were tabled in the Legislative Assembly
and are publicly available to Prince Edward Island residents.
It is also the intent of the Department of Health and Wellness
to recognize this important contribution in its 2014–2015
Annual Report.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
35
CHAPTER 3: PRINCE EDWARD ISLAND
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
146,049
147,942
148,278
146,751
146,170
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
7
7
7
7
7
172,100,500
183,647,900
192,480,600
197,008,800
206,026,400
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4. Number of private for-profit facilities
providing insured health services (#).
0
0
0
0
0
5. Payments to private for-profit facilities
for insured health services ($).
0
0
0
0
0
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
2,564
2,509
2,553
2,708
2,412
25,159,408
23,821,199
25,941,946
25,515,954
26,099,415
16,763
15,391
19,351
19,692
19,881
5,286,499
5,136,948
6,566,417
7,616,353
7,385,351
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
36
CANADA HEALTH ACT
29
43
24
40
20
70,768
164,610
76,120
157,594
55,418
113
165
125
137
93
44,213
58,796
43,482
45,756
53,285
ANNUAL REPORT 2014–2015
CHAPTER 3: PRINCE EDWARD ISLAND
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
242
232
344
318
331
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of not participating physicians (#).
0
0
0
0
0
14.Number of participating physicians (#).1
17. Total payments for services provided
by physicians paid through all payment
methods ($).
62,670,303
18.Total payments for services provided by
physicians paid through fee-for-service ($).
49,332,788
2
60,719,582
50,264,859
2
65,193,465
55,935,726
2
67,973,102
2
57,810,957
70,045,760
59,425,077
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
80,559
83,086
91,130
89,178
98,980
6,247,907
6,330,440
7,025,721
9,567,703
9,868,637
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
684
950
1,109
659
390
31,729
40,600
38,036
38,005
37,500
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
2
2
2
2
2
352
377
383
361
446
137,566
125,392
125,290
130,393
169,386
1. Prior to 2012–2013, the total does not include locums, visiting specialists or other non-complement physicians.
2. Prior to 2012–2013, data reported did not capture full comprehensive clinical payments. The reporting mechanism has been corrected such that all relevant
clinical payments are captured and presented in 2012–2013.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
37
2
38
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
NOVA SCOTIA
INTRODUCTION
The Nova Scotia Department of Health and Wellness’s vision
and mission are:
■■ Vision: Healthy People, Healthy Communities for
Generations
■■ Mission: Working together to achieve excellence in
health, healing and learning
The health and wellness system includes the delivery of health
care as well as the prevention of disease and injury and the
promotion of health and healthy living. The Department is
responsible for the following core program areas: mental health
and addiction services; partnerships and physician services;
pharmaceutical programs; primary health care; emergency
health services; continuing care; acute and tertiary care; health
system workforce; health care quality; public health; health
services emergency management; health information and
active living.
enhanced pharmaceutical coverage. Nova Scotia also has
much higher than average rates of chronic diseases such as
cancers and diabetes which contribute to the rising costs of
health care delivery.
Despite these ever increasing pressures and challenges,
Nova Scotia continues to be committed to the delivery of
medically necessary services consistent with the principles
of the Canada Health Act.
Additional information related to health care in Nova Scotia
may be obtained from the Department of Health and Wellness
website at http://novascotia.ca/DHW.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
On April 1, 2015, Nova Scotia will implement amendments
to the Health Authorities Act. The amendments will provide for
new roles for the Minister of Health and Wellness and the
health authorities. The amendments will also provide for the
establishment of the Nova Scotia Health Authority, which
is a consolidation of nine former district health authorities.
The Minister of Health and Wellness will be responsible
for: providing leadership for the health system by setting the
strategic policy direction, priorities and standards for the
health system; and ensuring accountability for funding and for
the measuring and monitoring of health system performance.
The health authorities (Nova Scotia Health Authority and
the Izaak Walton Killam Health Centre — NSHA & IWK
respectively) will be responsible for: governing, managing and
providing health services in the Province and implementing
the strategic direction set out in the provincial health plan;
and engaging with the communities they serve, through the
community health boards.
Two plans cover insured health services in Nova Scotia:
the Hospital Insurance and the Medical Services Insurance
(MSI) Plans.
Nova Scotia faces a number of challenges in the delivery
of health care services. Nova Scotia’s population is
aging. Approximately 18.9 percent of the Nova Scotian
population is 65 or older; this figure is expected to reach
28.1 percent by 2030. In response to the needs of the aging
population, Nova Scotia has expanded its basket of publicly
insured services to include home care, long term care, and
The Department of Health and Wellness and Medavie Blue
Cross Incorporated entered into a service level agreement,
effective August 1, 2005. Under the agreement, Medavie
Blue Cross Incorporated is responsible for operating and
administering programs contained under MSI, Pharmacare
Programs and Health Card Registration Services.
The Department of Health and Wellness administers the
Hospital Insurance Plan, which operates under the Health
Services and Insurance Act, Chapter 197, Revised Statutes of
Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18 and 35.
The MSI Plan is administered and operated by an authority
consisting of the Department of Health and Wellness and
Medavie Blue Cross Incorporated, under the above-mentioned
Act (sections 8, 13, 17(2), 23, 27, 28, 29, 30, 31, 32 and 35).
Section 8 of the Act gives the Minister of Health and Wellness,
with approval of the Governor in Council, the power to
enter into agreements and vary, amend or terminate the same
agreements with such person or persons as the Minister deems
necessary to establish, implement and carry out the MSI Plan.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
39
CHAPTER 3: NOVA SCOTIA
1.2 Reporting Relationship
In the service level agreement, Medavie Blue Cross Incorporated
is obliged to provide reports to the Department under various
Statements of Requirements for each Business Service
Description as listed in the contract. Medavie Blue Cross
Incorporated is audited every year on various areas of reporting.
Section 17(1)(i) of the Health Services and Insurance Act, and
sections 11(1) and 12(1) of the Hospital Insurance Regulations,
under this Act, set out the terms for reporting by hospitals and
hospital boards to the Minister of Health and Wellness.
1.3 Audit of Accounts
The Auditor General audits all expenditures of the Department
of Health and Wellness. Under its service level agreement with
the Department of Health and Wellness, Medavie Blue Cross
Incorporated provides audited financial statements of MSI
costs to the Department of Health and Wellness. The Auditor
General and the Department of Health and Wellness have the
right to perform audits of the administration of the agreement
with Medavie Blue Cross Incorporated.
All long-term care facilities, home care and home support
agencies are required to provide the Department of Health and
Wellness with annual audited financial statements.
Under section 34(5) of the Health Authorities Act, every hospital
board is required to submit to the Minister of Health and
Wellness, by July 1st each year, an audited financial statement
for the preceding fiscal year.
1.4 Designated Agency
Medavie Blue Cross Incorporated administers and has the
authority to receive monies to pay physician accounts under the
service level agreement with the Department of Health and
Wellness. Medavie Blue Cross Incorporated receives written
authorization from the Department of Health and Wellness
to make these payments. The rates of pay and specific amounts
depend on the physician contract negotiated between Doctors
Nova Scotia and the Department of Health and Wellness.
The Department of Health and Wellness and the Office of the
Auditor General, have the right, under the terms of the service
level agreement, to audit all MSI and Pharmacare transactions.
health card administration, physician claims activity, financial
monitoring, provider management, audit activities and program
utilization. These reports are submitted on a monthly, quarterly,
or annual basis. A complete list of reports can be obtained from
the Nova Scotia Department of Health and Wellness.
As part of an agreement with the Department of Health and
Wellness, QSI also provides monthly, quarterly, and annual
reports with regard to dental programs in Nova Scotia. This
includes dental services provided in-hospital as outlined in
the Canada Health Act. These reports address provider claims
and payment, program utilization, and audit. A complete list
of reports can be obtained from the Nova Scotia Department
of Health and Wellness.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
Nine district health authorities and the Izaak Walton Killam
(IWK) Health Centre — a women and children’s tertiary care
hospital — deliver insured hospital services to both in-patients
and out-patients in Nova Scotia. The process for transitioning
from nine provincial health authorities to one (Nova Scotia
Health Authority) began in 2014–2015 and will officially be
in place April 1, 2015.
Accreditation is not mandatory, but all facilities are accredited
at a facility or district level. The enabling legislation that
provides for insured hospital services in Nova Scotia is the
Health Services and Insurance Act, Chapter 197, Revised Statutes
of Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18
and 35, passed by the Legislature in 1958. Hospital Insurance
Regulations were made pursuant to the Health Services and
Insurance Act.
The Insured Health Services Act was passed in December 2012,
but has not yet been proclaimed. It will replace the current
Health Services and Insurance Act which provides the statutory
framework for health insurance programs in Nova Scotia.
The new Act aims to modernize existing legislation (in place
since 1973) and it commits to the principles of the Canada
Health Act with the intent of ensuring equitable access to
insured health services.
Under the Hospital Services Insurance Plan, in-patient
services include:
Quikcard Solutions Incorporated (QSI) administers and has the
authority to receive monies to pay dentists under a service level
agreement with the Department of Health and Wellness. The
tariff of dental fees is negotiated between the Nova Scotia Dental
Association and the Department of Health and Wellness.
■■ accommodation and meals at the standard ward level;
Medavie Blue Cross Incorporated is responsible for providing
approximately 85 reports to the Department pertaining to
■■ use of operating room(s), case room(s) and anaesthetic
40
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
■■ necessary nursing services;
■■ laboratory, radiological and other diagnostic procedures;
■■ routine surgical supplies;
services;
CHAPTER 3: NOVA SCOTIA
■■ use of radiotherapy and physiotherapy services for in-patients,
where available; and
■■ blood or therapeutic blood fractions.
Out-patient services include:
■■ laboratory and radiological examinations;
■■ diagnostic procedures involving the use of
radio-pharmaceuticals;
■■ electroencephalographic examinations;
■■ use of occupational and physiotherapy facilities,
where available;
■■ necessary nursing services;
■■ drugs, biologicals and related preparations;
■■ blood or therapeutic blood fractions;
■■ hospital services in connection with most minor medical
and surgical procedures;
■■ day-patient diabetic care;
■■ services provided by the Nova Scotia Hearing and
Speech Clinics, where available;
■■ ultrasonic diagnostic procedures;
■■ home parenteral nutrition, where available; and
■■ haemodialysis and peritoneal dialysis, where available.
Each year district health authorities and the IWK Health
Centre submit business plans outlining budgets and
priorities for the coming year to ensure safe and high quality
access to care. Plans are evaluated through a centralized
process by the Department of Health and Wellness and
approved by Executive Council. Beginning in 2015,
under the amended Health Authorities Act, which comes
into force April 1, 2015, health authority business plans
will be submitted on November 1st every year and will be
approved by the Minister of Health and Wellness.
2.2 Insured Physician Services
The legislation covering the provision of insured physician
services in Nova Scotia is the Health Services and Insurance Act,
sections 3(2), 5, 8, 13, 13A, 17(2), 22, 27–31, 35 and the
Medical Services Insurance Regulations.
As of March 31, 2015, 2,580 physicians were paid through the
Medical Services Insurance (MSI) Plan.
Physicians retain the ability to opt in or out of the MSI Plan.
In order to opt out, a physician notifies MSI, relinquishing his
or her billing number. MSI reimburses patients who pay the
physician directly due to opting out. As of March 31, 2015,
no physicians had opted out.
Insured services include those that are medically necessary.
Medically necessary may be defined as services provided by
a physician to a patient with the intent to diagnose or treat
physical or mental disease or dysfunction, as well as those
services generally accepted as promoting health through
prevention of disease or dysfunction. Services that are not
medically necessary are not insured. Services explicitly deemed
as non-insured under the Health Services and Insurance Act
or its regulations remain uninsured regardless of individual
judgments regarding the medical necessity.
Additional services were added to the list of insured physician
services in 2014–2015. A complete list can be obtained from
the Nova Scotia Department of Health and Wellness. On an as
needed basis, new specific fee codes are approved that represent
enhancements, new technologies or new ways of delivering
a service.
The addition of new fee codes, or adjustment to existing fee
codes, to the list of insured physician services is accomplished
through a collaborative Department of Health and Wellness,
Health Authority and Doctors Nova Scotia committee
structure. Physicians wishing to have a new fee code added
to the MSI Physician Manual submit a formal application to
the Fee Schedule Advisory Committee (FSAC) for review.
Each request is thoroughly researched. FSAC then makes a
recommendation to the Master Agreement Steering Group
(MASG) which either approves or denies the proposal. The
MASG Committee is comprised of equal representation
from Doctors Nova Scotia and the Department of Health
and Wellness. If the fee is approved, Medavie Blue Cross
Incorporated is directed to add the new fee to the schedule
of insured services payable by the MSI Plan.
2.3 Insured Surgical-Dental Services
To provide insured surgical-dental services under the Health
Services and Insurance Act, dentists must be registered members
of the Nova Scotia Dental Association and must also be
certified competent in the practice of dental surgery. The Health
Services and Insurance Act is written so that a dentist may choose
not to participate in the MSI Plan. To participate, a dentist
must register with MSI. A participating dentist who wishes
to reverse election to participate must advise MSI in writing
and is then no longer eligible to submit claims to MSI. In
2014–2015, 25 dentists submitted claims through the MSI Plan
for providing insured surgical-dental services.
Insured surgical-dental services must be provided in a health
care facility. Insured services are detailed in the Department
of Health and Wellness MSI Dentist Manual (Dental Surgical
Services Program) and are reviewed annually through the
Partnerships and Physician Services Branch. Services under
this program are insured when the conditions of the patient
are such that it is medically necessary for the procedure to be
done in a hospital and the procedure is of a surgical nature.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
41
CHAPTER 3: NOVA SCOTIA
Generally included as insured surgical-dental services are
orthognathic surgery, surgical removal of impacted teeth, and
oral and maxillofacial surgery. Requests for an addition to the
list of surgical-dental services are accomplished through the
Dental Association of Nova Scotia who forwards a proposal to
the Department of Health and Wellness. Then, in consultation
with experts in the field, the Department renders a decision on
the addition of the procedure as an insured service.
Insured services in the “Other extraction services” (routine
extractions) category are approved for the following
groups of patients: cardiac patients, transplant patients,
immunocompromised patients, and radiation patients.
This is the case only when patients are undergoing
active treatment in a hospital setting and the attendant
medical procedure must require the removal of teeth that
would otherwise be considered routine extractions.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital services include:
■■ preferred accommodation at the patient’s request;
■■ telephones;
■■ drugs and biologicals ordered after discharge from hospital;
■■ cosmetic surgery;
■■ reversal of sterilization procedures;
■■ in-vitro fertilization;
■■ procedures performed as part of clinical research trials;
■■ services such as gastric bypass for morbid obesity, breast
reduction/augmentation and newborn circumcision
(These services may be insured when approved as special
consideration for medical reasons only); and
■■ services not deemed medically necessary that are required
by third parties, such as insurance companies.
Uninsured Physician Services include:
■■ services available to residents of Nova Scotia that are
covered under any statute or law of any other jurisdiction,
either within or outside of Canada;
■■ diagnostic, preventive or other physician’s services
available through the Nova Scotia Hospital Insurance
Program, the Department of Health and Wellness, or other
government agencies;
■■ services at the request of a third party;
■■ provision of a prescription or a requisition for a diagnostic
or therapeutic service provided to a patient without
a clinical evaluation;
CANADA HEALTH ACT
■■ services performed for cosmetic purposes only;
■■ group immunizations performed without receiving
preapproval by MSI;
■■ acupuncture;
■■ electrolysis;
■■ reversal of sterilization;
■■ in vitro fertilization;
■■ provision of travel vaccines;
■■ newborn circumcision;
■■ release of tongue tie in newborn;
■■ removal of cerumen, except in the case of a febrile child;
■■ treatment of warts or other benign conditions of the skin;
■■ comprehensive visits when there are no signs, symptoms or
family history of disease or disability;
■■ services, supplies and other materials not part of office
overhead, including for example, photocopying or other
costs associated with transfer of records;
■■ items such as drugs, dressings, and tray fees; physician’s
advice by telephone, letter, fax or email, with exceptions; and
■■ mileage or travelling time.
■■ televisions;
42
■■ physician’s services provided to their own families;
ANNUAL REPORT 2014–2015
Of note is the removal of sex reassignment surgery from the
explicit list of services that are not insured through MSI. Sex
reassignment surgery became an insured service April 1, 2014.
Major third party agencies currently purchasing medically
necessary health services in Nova Scotia include Workers’
Compensation and the Department of National Defence.
All residents of the province are entitled to services covered
under the Health Services and Insurance Act. If enhanced goods
and services, such as foldable intraocular lens or fiberglass
casts, are offered as an alternative, the specialist or physician
is responsible to ensure that the patient is aware of their
responsibility for the cost. Patients are not denied service based
on their inability to pay. The province provides alternatives to
any of the enhanced goods and services.
The Department of Health and Wellness carefully reviews all
patient complaints or public concerns that may indicate that the
general principles of insured services are not being followed.
If a service or procedure is deemed by the Department of
Health and Wellness not to be medically necessary, it is
removed from the physician fee schedule and will no longer be
reimbursed to physicians as an insured service. Once a service
has been de-insured, all procedures and testing relating to the
provision of that service also become de-insured. The same also
applies to dental services and hospital services. The last time
there was any significant de-insurance of services was in 1997.
CHAPTER 3: NOVA SCOTIA
3.0UNIVERSALITY
3.1Eligibility
Eligibility for insured health care services in Nova Scotia is outlined under section 2 of the Hospital Insurance Regulations made
pursuant to section 17 of the Health Services and Insurance Act.
All residents of Nova Scotia are eligible. A resident is defined as
anyone who is legally entitled to stay in Canada and who makes
his or her home and is ordinarily present in Nova Scotia.
In 2014–2015, a person is considered to be “ordinarily present”
in Nova Scotia if the person:
■■ makes his or her permanent home in Nova Scotia;
■■ is physically present in Nova Scotia for at least 183 days
in any calendar year (short term absences under 30 days,
within Canada, are not monitored); and
■■ is a Canadian citizen or “Permanent Resident” as defined
by Citizenship and Immigration Canada.
Persons moving to Nova Scotia from another Canadian
province will normally be eligible for Medical Services
Insurance (MSI) on the first day of the third month following
the month of their arrival. Persons moving permanently to
Nova Scotia from another country are eligible on the date
of their arrival in the province, provided they are Canadian
citizens or hold “Permanent Resident” status as defined by
Citizenship and Immigration Canada.
Individuals insured under the Workers’ Compensation Act or any
other Act of the Legislature or of the Parliament of Canada,
or under any statute or law of any other jurisdiction either
within or outside Canada, are not eligible for MSI coverage
(such as members of the Canadian Forces, federal inmates
and some classes of refugees). Once individuals are no longer
covered under any of the Acts, statutes or laws noted above,
they are then eligible to apply and receive Nova Scotia health
insurance coverage, provided that they are either a Canadian
citizen or a permanent resident as defined by Citizenship and
Immigration Canada.
In 2014–2015, the total number of residents registered with the
health insurance plan was 1,001,708.
3.2 Other Categories of Individuals
Other individuals may be eligible for insured health care
services in Nova Scotia if they meet specific eligibility criteria
listed below:
Immigrants: Persons moving from another country to live
permanently in Nova Scotia are eligible for health care on the
date of arrival. They must possess a landed immigrant document.
These individuals, formerly called “landed immigrants,” are now
referred to as “permanent residents.”
Non-Canadians married to Canadian Citizens or Permanent
Residents (copy of marriage certificate required), who possess
the required documentation from Citizenship and Immigration
Canada indicating they have applied for permanent residency,
will be eligible for coverage on the date of arrival in Nova Scotia
(if applied prior to their arrival to Nova Scotia), or the date of
application for permanent residency (if applied after their arrival
in Nova Scotia).
Convention refugees or persons in need of protection who
possess the required documentation from Citizenship
and Immigration Canada indicating they have applied for
permanent residency will be eligible for coverage on the date
of application for permanent residency.
In 2014–2015, there were 37,835 permanent residents registered
with the health care insurance plan.
Refugees: Refugees are eligible for MSI once they have
been granted permanent residency status by Citizenship and
Immigration Canada, or if they possess either a work permit
or study permit.
Work Permits: Persons moving to Nova Scotia from outside the
country who possess a work permit can apply for coverage on the
date of arrival in Nova Scotia, provided they will be remaining
in Nova Scotia for at least one full year. A declaration must be
signed to confirm that the worker will not be outside Nova Scotia
for more than 31 consecutive days, unless required in the course
of employment. MSI coverage is extended for a maximum
of 12 months at a time. Each year, a copy of their renewed
immigration document must be presented and a declaration
signed. Dependants of such persons, who are legally entitled to
remain in Canada, are granted coverage on the same basis.
Once coverage has terminated, the person is to be treated as
never having qualified for health services coverage as herein
provided and must comply with the above requirements before
coverage will be extended to them or their dependants.
In 2014–2015, there were 3,019 individuals with Employment
Authorizations covered under the health care insurance plan.
Study Permits: Persons moving to Nova Scotia from another
country and who possess a Study Permit will be eligible for
MSI on the first day of the thirteenth month following the
month of their arrival, provided they have not been absent
from Nova Scotia for more than 31 consecutive days, unless
required in the course of their studies. MSI coverage is extended
for a maximum of 12 months at a time and only for services
received within Nova Scotia. Each year, a copy of their renewed
immigration document must be presented and a declaration
signed. Dependants of such persons, who are legally entitled
to remain in Canada, will be granted coverage on the same basis
once the student has gained entitlement.
In 2014–2015, there were 1,467 individuals with Student
Authorizations covered under the health care insurance plan.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
43
CHAPTER 3: NOVA SCOTIA
4.0PORTABILITY
4.3 Coverage During Temporary Absences
Outside Canada
4.1 Minimum Waiting Period
Nova Scotia adheres to the Agreement on Eligibility and
Portability for dealing with insured services for residents
temporarily outside Canada. Provided a Nova Scotia resident
meets eligibility requirements, out-of-country services will be
paid, at a minimum, on the basis of the amount that would
have been paid by Nova Scotia for similar services rendered
in this province. In order to be covered, procedures of a nonemergency nature must have prior approval before they will
be covered by MSI.
Persons moving to Nova Scotia from another Canadian
province or territory will normally be eligible for Medical
Services Insurance (MSI) on the first day of the third month
following the month of their arrival.
4.2 Coverage During Temporary Absences
in Canada
The Interprovincial Agreement on Eligibility and Portability
is followed in all matters pertaining to the portability of
insured services.
Generally, the Nova Scotia MSI Plan provides coverage for
residents of Nova Scotia who move to other provinces or
territories for a period of three months, per the Eligibility
and Portability Agreement. Students and their dependants,
who are temporarily absent from Nova Scotia and in full-time
attendance at an educational institution, may remain eligible
for MSI on a yearly basis. To qualify for MSI, the student must
provide to MSI a letter directly from the educational institution
which states that they are registered as a full-time student. MSI
coverage will be extended on a yearly basis pending receipt of
this letter.
Workers who leave Nova Scotia to seek employment elsewhere
will still be covered by MSI for up to 12 months, provided
they do not establish residence in another province or territory.
Services provided to Nova Scotia residents in other provinces
or territories are covered by reciprocal agreements. Nova Scotia
participates in the Hospital Reciprocal Billing Agreement and
the Medical Reciprocal Billing Agreement. Québec is the only
province that does not participate in the Medical Reciprocal
Billing Agreement. Nova Scotia pays for services provided by
Québec physicians to Nova Scotia residents at Québec rates if
the services are insured in Nova Scotia. The majority of such
claims are received directly from Québec physicians. In-patient
hospital services are paid through the interprovincial reciprocal
billing arrangement at the standard ward rate of the hospital
providing the service. Nova Scotia pays the host province rates
for insured services in all reciprocal billing situations.
The total amount paid by the plan in 2014–2015 for in-patient
and out-patient hospital services received in other provinces and
territories was $31,336,298.
As of August 1, 2014 Nova Scotia residents are permitted out
of province for vacation for one additional month. This allows
Nova Scotians to have a vacation outside of the province for
seven months in each calendar year and continue to be eligible
for MSI.
44
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
As of August 1, 2014 Nova Scotia residents are permitted out
of country for vacation for one additional month. This allows
Nova Scotians to have a vacation outside of the country for
seven months in each calendar year and continue to be eligible
for MSI.
Students and their dependants who are temporarily absent
from Nova Scotia and in full-time attendance at an educational
institution outside Canada may remain eligible for MSI on a
yearly basis. To qualify for MSI, the student must provide to
MSI a letter obtained from the educational institution that
verifies the student’s attendance there in each year for which
MSI coverage is requested.
Persons who engage in employment (including volunteer,
missionary work or research) outside Canada which does not
exceed 24 months are still covered by MSI, providing the
person has already met the residency requirements.
The total amount spent in 2014–2015 for insured in-patient
services provided outside of Canada was $777,019. Nova Scotia
does not cover out-patient services out of country.
4.4 Prior Approval Requirement
Prior approval must be obtained for elective services outside the
country. Application for prior approval is made to the Medical
Director of the MSI Plan by a specialist in Nova Scotia on
behalf of an insured resident. The medical consultant reviews
the terms and conditions and determines whether or not the
service is available in the province, or if it can be provided in
another province or only out-of-country. The decision of the
medical consultant is relayed to the patient’s referring specialist.
If approval is given to obtain service outside the country, the
full cost of that service will be covered under MSI.
CHAPTER 3: NOVA SCOTIA
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
Section 3 of the Health Services and Insurance Act states that
subject to this Act and the regulations, all residents of the
province are entitled to receive insured hospital services from
hospitals on uniform terms and conditions. As well, all residents
of the province are insured on uniform terms and conditions in
respect of the payment of insured professional services to the
extent of the established tariff. There are no user charges or
extra charges allowed under the plan.
Nova Scotia continually reviews access situations across
Canada to ensure equity of access. In areas where improvement
is deemed necessary, depending on the province’s financial
situation, extra funding is generally allocated to that need.
Eight Collaborative Emergency Centers (CECs) are now
open to provide Nova Scotians living in smaller communities
expanded access to primary health care, same day or next day
access to appointments and 24/7 access to emergency care.
Emergency Department closures have been significantly
reduced at CEC sites. The Department has worked with system
partners to address several other areas of health care access. The
current focus is the introduction of Emergency Care Standards
across the province.
The province committed to begin a process of transitioning
from nine district health authorities to one provincial health
authority. The new structure will create a health system that is
focused on province-wide solutions. This new structure will be
in place by April 1, 2015.
Alternative Payment Plans for physicians continued to be
implemented and/or expanded to improve recruitment in rural
and hard-to-fill areas, improving access to primary health care
in those communities.
5.2 Physician Compensation
The Health Services and Insurance Act, RS Chapter 197 governs
payment to physicians and dentists for insured services.
Physician payments are made in accordance with a negotiated
agreement between Doctors Nova Scotia (the sole bargaining
agent for physicians) and the Nova Scotia Department of
Health and Wellness. Fee-for-service is still the most prevalent
method of payment for physician services; however, there has
been significant growth in the number of alternative payment
arrangements in place in Nova Scotia.
In the 1997–1998 fiscal year, about 9 percent of doctors
were paid solely through alternative funding. In 2014–2015,
approximately 24 percent of physicians were remunerated
exclusively through alternative funding. Approximately
65 percent of physicians in Nova Scotia receive all or a portion
of their remuneration through alternative funding mechanisms
such as academic funding agreements with clinical departments
for the provision of clinical, academic, administrative and
research services; alternative payment plans for individual
physicians and groups used mostly in rural areas; and other
funding programs such as emergency agreements and
sessional funding.
Payment rates for dental services in the province are negotiated between the Department of Health and Wellness and the
Nova Scotia Dental Association following a process similar to
physician negotiations. Dentists are generally paid on a feefor-service basis, pediatric dentists at the IWK Health Centre
receive remuneration through an Academic Funding Plan.
5.3 Payments to Hospitals
The Department of Health and Wellness establishes budget
targets for health care services. It does this by receiving business
plans from the nine district health authorities (DHAs), the
IWK Health Centre and other non-DHA organizations.
Approved provincial estimates form the basis on which
payments are made to these organizations for service delivery.
The Health Authorities Act was given Royal Assent on
June 8, 2000. The Act instituted the nine DHAs and the
IWK that replaced the former regional health boards. The
DHAs and the IWK are responsible for overseeing the delivery
of health services in their districts, and are fully accountable
for explaining their decisions on the community health plans
through their business plan submissions to the Department
of Health and Wellness. The Act has been amended and the
changes will come into force April 1, 2015. The amendments
provide for the consolidation of the nine district health
authorities into one provincial health authority, the Nova Scotia
Health Authority (NSHA). The IWK will remain as a health
authority. The NSHA and IWK will be required to work
collaboratively in delivering services to Nova Scotians.
Section 10 of the Health Services and Insurance Act and sections 9
through 13 of the Hospital Insurance Regulations define the
terms for payments by the Minister of Health and Wellness to
hospitals for insured hospital services.
In 2014–2015, there were 3,069 hospital beds in Nova Scotia
(3.3 beds per 1,000 population). Department of Health and
Wellness direct expenditures for insured hospital services
operating costs were increased to $1,735,234,990.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
45
CHAPTER 3: NOVA SCOTIA
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
In Nova Scotia, the Health Services and Insurance Act
acknowledges the federal contribution regarding the cost of
insured hospital services and insured health services provided
to provincial residents. The residents of Nova Scotia are aware
of ongoing federal contributions to Nova Scotia health care
through the Canada Health Transfer (CHT) as well as other
federal funds through press releases and media coverage.
The Government of Nova Scotia also recognized the federal
contribution under the CHT in various published documents,
including the following documents:
■■ Public Accounts 2013–2014 released July 24, 2014; and
■■ Budget Estimates and Supplementary Detail 2014–2015
released April 3, 2014.
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CANADA HEALTH ACT
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CHAPTER 3: NOVA SCOTIA
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
988,585
994,018
998,763
1,000,124
1,001,708
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public facilities
2. Number (#).
3. Payments for insured health services ($).1
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#). 2
5. Payments to private for-profit facilities
for insured health services ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
35
35
35
35
35
1,560,236,537
1,593,552,159
1,619,915,286
1,679,289,646
1,735,234,990
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1,946
2,402
2,259
2,034
2,020
13,614,172
19,417,809
19,854,352
18,363,912
17,984,193
38,261
36,125
39,611
39,551
41,207
10,978,035
12,375,773
12,272,547
12,888,192
13,352,105
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
not available
not available
not available
not available
not available
788,368
2,176,921
1,104,701
1,242,889
777,019
12.Total number of claims, out-patient (#).
not applicable
not applicable
not applicable
not applicable
not available
13.Total payments, out-patient ($).
not applicable
not applicable
not applicable
not applicable
not available
11. Total payments, in-patient ($).
1. This reflects payments made to the public facilities noted for indicator 2 above.
2. Scotia Surgery is not considered private; it is designated as a hospital under the Health Authorities Act (funded by the Department of Health and Wellness). The
Nova Scotia Health Authority (NSHA) rents available capacity at Scotia Surgery. Procedures performed at Scotia Surgery are scheduled by NSHA staff and
completed by surgeons in the public system. Scotia Surgery has no involvement in managing the physician or patient scheduling. Patients are scheduled based on
the same criteria utilized for scheduling at other Central Zone sites.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
47
CHAPTER 3: NOVA SCOTIA
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
2,434
2,473
2,507
2,581
2,580
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
17. Total payments for services provided
by physicians paid through all payment
methods ($).
661,968,168
681,963,292
694,184,053
712,629,560
730,417,814
18.Total payments for services provided by
physicians paid through fee-for-service ($).
301,629,014
309,391,089
310,301,903
310,882,780
317,605,144
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of non-participating physicians (#).
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
195,538
211,030
208,505
204,888
210,771
7,426,414
8,297,188
8,512,631
8,607,696
8,884,002
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
3,092
3,295
2,096
3,141
2,789
169,312
185,142
110,695
173,452
157,344
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
23.Number of participating dentists (#).
24.Number of services provided (#). 3
25.Total payments ($). 4
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
26
28
21
26
25
6,913
7,228
7,007
7,391
8,492
1,459,608
1,338,592
1,397,223
1,356,416
1,442,994
3. Total services includes block funded dentists.
4. Total payments does not include block funded dentists.
48
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
NEW BRUNSWICK
INTRODUCTION
1.2 Reporting Relationship
During 2014–2015, New Brunswick’s health system partners
continued their efforts to ensure the health care system
remained effective, efficient and affordable. Through the work
of all the health partners — Horizon Health Network, Vitalité
Health Network, FacilicorpNB, NB Health Council and the
Department of Health — they collectively worked towards
improving the system’s performance to better meet the needs
of today and, tomorrow while continuing a commitment to the
five fundamental principles under the Canada Health Act.
The Medicare—Insured Services Branch and the Medicare—
Eligibility and Claims Branch of the Department are mandated
to administer the Medical Services Plan. The Minister reports
to the Legislative Assembly through the Department’s annual
report and through regular legislative processes.
For information concerning any of the province’s health
programs and services, please visit the New Brunswick
Ministry of Health website at: www.gnb.ca/health
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
In New Brunswick, the formal name for Medicare is the
Medical Services Plan. The Minister of Health (Minister) is
responsible for operating and administering the plan by virtue
of the Medical Services Payment Act and its regulations. The Act
and regulations set out who is eligible for Medicare coverage, the
rights of the patient, and the responsibilities of the Department
of Health (the Department). This law establishes a Medicare
plan, and defines which Medicare services are covered and
which are excluded. It also stipulates the type of agreements the
Department may enter into with provinces and territories and
with the New Brunswick Medical Society. As well, it specifies
the rights of a medical practitioner; how the amounts to be paid
for medical services will be determined; how assessment of
accounts for medical services may be made; and confidentiality
and privacy issues as they relate to the administration of the Act.
The Regional Health Authorities Act establishes the regional
health authorities (RHAs) and sets forth the powers, duties,
and responsibilities of the same. The Minister is responsible
for the administration of the Act, provides direction to each
RHA, and may delegate additional powers, duties or functions
to the RHAs.
1.3 Audit of Accounts
Three groups have a mandate to audit the Medical Services Plan.
The Office of the Auditor General: In accordance with
the Auditor General Act, the Office of the Auditor General
conducts the external audit of the accounts of the Province of
New Brunswick, which includes the financial records of the
Department. The Auditor General also conducts management
reviews on programs as he or she sees fit.
The Office of the Comptroller: The Comptroller is the
chief internal auditor for the Province of New Brunswick
and provides accounting, audit and consulting services in
accordance with responsibilities and authority set out in
the Financial Administration Act.
Monitoring and Compliance Team: This team is tasked with
managing compliance with the Medical Payment Services Act
and regulations, as well as the Negotiated Fee Schedule.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
49
CHAPTER 3: NEW BRUNSWICK
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
Legislation providing for insured hospital services includes the
Hospital Services Act, section 9 of Regulation 84–167, and the
Hospital Act. Under Regulation 84–167 of the Hospital Services
Act, New Brunswick residents are entitled to the following
insured hospital services:
Insured in-patient services include: accommodation and
meals; nursing; laboratory/diagnostic procedures; drugs; the
use of facilities (e.g., surgical, radiotherapy, physiotherapy);
and services provided by professionals within the facility.
Insured out-patient services include: laboratory and
diagnostic procedures; mammography; and the hospital
component of available out-patient services for maintaining
health, preventing disease and helping diagnose or treat any
injury, illness or disability, excluding those related to the
provision of drugs or third party diagnostic requests.
2.2 Insured Physician Services
The Medical Services Payment Act and corresponding regulations
provide for insured physician services. As of March 31, 2015
there were 1,631 participating physicians in New Brunswick.
No physicians rendering health care services elected to opt out
of the Medical Services Plan. When a physician opts out of
Medicare, they must complete the specified Medicare claim
form and indicate the amount charged to the patient. The
beneficiary then seeks reimbursement by certifying on the
claim form that the services have been received and forwarding
the claim form to Medicare. The charges must not exceed the
Medicare tariff. If the charges are in excess of the Medicare
tariff, the practitioner must inform the beneficiary before
rendering the service that:
■■ they have opted out and charge fees above the Medicare tariff;
■■ in accepting services under these conditions, the patient
waives all rights to Medicare reimbursement;
■■ the patient is entitled to seek services from another prac­
titioner who participates in the Medical Services Plan; and
■■ the physician must obtain a signed waiver from the patient
on the specified form and forward the form to Medicare.
The services which residents are entitled to under Medicare
include:
a) the medical portion of all medically required services
rendered by medical practitioners; and
b) certain surgical-dental procedures when performed by
a physician or a dental surgeon in a hospital.
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CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
A physician or the Department may request the addition
of a new service. All requests are considered by the New
Service Items Committee, which is jointly managed by the
New Brunswick Medical Society and the Department. The
decision to add a new service is usually based on conformity to
the definition of “medically necessary” and whether the service
is considered generally acceptable practice (not experimental)
within New Brunswick and/or Canada. Considerations under
the term “medically necessary” include services required for
maintaining health, preventing disease and/or diagnosing or
treating an injury, illness or disability. No public consultation
process is used.
In 2014–2015 no new services were added to the list of
insured services.
2.3 Insured Surgical-Dental Services
Schedule 4 of Regulation 84–20 under the Medical Services
Payment Act identifies the insured surgical-dental services that
can be provided by a qualified dental practitioner in a hospital,
providing the condition of the patient requires services to be
rendered in a hospital.
In addition, a general dental practitioner may be paid to assist
another dentist for medically required services under some
conditions. In addition to Schedule 4 of Regulation 84–20,
oral maxillofacial surgeons (OMS) have added access to
approximately 300 service codes in the Physician Manual
and can admit or discharge patients and perform physical
examinations, including those performed in an out-patient
setting. OMSs may also see patients for consultation in
their office.
As of March 31, 2015, there were just over 100 OMSs
and dentists registered in New Brunswick; in 2014–2015,
18 provided services insured under the Medical Services Plan.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital services include: take-home drugs; thirdparty requests for diagnostic services; visits to administer drugs;
vaccines; sera or biological products; televisions and telephones;
preferred accommodation at the patient’s request; and hospital
services directly related to services listed under Schedule 2
of the Regulation under the Medical Services Payment Act.
Services are not insured if provided to those entitled under
other statutes.
The services listed in Schedule 2 of New Brunswick Regulation
84–20 under the Medical Services Payment Act are specifically
excluded from the range of entitled medical services under
Medicare. They are as follows:
CHAPTER 3: NEW BRUNSWICK
■■ elective plastic surgery or other services for cosmetic purposes;
■■ correction of inverted nipple;
■■ breast augmentation;
■■ otoplasty for persons over the age of eighteen;
■■ removal of minor skin lesions, except where the lesions are,
or are suspected to be, pre-cancerous;
■■ abortion, unless the abortion is performed in a hospital
■■ trans-sexual surgery;
■■ radiology services provided in the province by a private
radiology clinic;
■■ acupuncture;
■■ complete medical examinations when performed for
the purposes of periodic check-up and not for medically
necessary purposes;
facility approved by the jurisdiction in which the hospital
facility is located;
■■ circumcision of a newborn;
is required because of risk of procedural failure, other than
risk inherent in the removal of the cataract itself, due to
existence of an illness or other complication;
■■ reversal of tubal ligations;
■■ surgical assistance for cataract surgery unless such assistance
■■ medicines, drugs, materials, surgical supplies or prosthetic
devices;
■■ advice or prescription renewal by telephone which is not
specifically provided for in the Schedule of Fees;
■■ examination of medical records or certificates at the request
of a third party, or other services required by hospital
regulations or medical by-laws;
■■ dental services provided by a medical practitioner or an oral
and maxillofacial surgeon;
■■ services that are generally accepted within New Brunswick
as experimental or that are provided as applied research;
■■ services that are provided in conjunction with, or in relation to,
the services referred to above;
■■ testimony in a court or before any other tribunal;
■■ immunization, examinations or certificates for purpose of
travel, employment, emigration, insurance or at the request
of any third party;
■■ services provided by medical practitioners or oral and maxil-
lofacial surgeons to members of their immediate family;
■■ psychoanalysis;
■■ electrocardiogram (E.C.G.) where not performed by a
specialist in internal medicine or paediatrics;
■■ laboratory procedures not included as part of an examination
or consultation fee;
■■ refractions;
■■ services provided within the province by medical
practitioners, oral and maxillofacial surgeons or dental
practitioners for which the fee exceeds the amount payable
under regulation;
■■ reversal of vasectomies;
■■ second and subsequent injections for impotence;
■■ intrauterine insemination;
■■ bariatric surgery unless the person has a body mass index of
40 or greater or of 35 or greater but less than 40, as well as
obesity-related comorbid conditions;
■■ venipuncture for purposes of taking blood when performed
as a stand-alone procedure in a facility that is not an
approved hospital facility.
Dental services not specifically listed in Schedule 4 of the
Dental Schedule are not covered by the Plan. Those listed in
Schedule 2 are considered the only non-insured medical services. There are no specific policies or guidelines, other than
the Act and regulations, to ensure that charges for uninsured
medical goods and services (e.g., fiberglass casts), provided in
conjunction with an insured health service, do not compromise
reasonable access to insured services.
The decision to de-insure physician or surgical-dental services
is based on the conformity of the service to the definition of
“medically necessary,” a review of medical service plans across
the country, and the previous use of the particular service.
Once a decision to de-insure is reached, the Medical Services
Payment Act dictates that the government may not make any
changes to the Regulation until the advice and recommendations of the New Brunswick Medical Society are received or
until the period within which the Society was requested by
the Minister to furnish advice and make recommendations
has expired. Subsequent to receiving their input and resolution
of any issues, a regulatory change is completed. Physicians are
informed in writing following notification of approval. The
public is usually informed through a media release. No public
consultation process is used.
In 2014–2015, no services were removed from the insured
services list.
■■ the fitting and supplying of eye glasses or contact lenses;
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
51
CHAPTER 3: NEW BRUNSWICK
3.0UNIVERSALITY
3.1Eligibility
Sections 3 and 4 of the Medical Services Payment Act and
Regulation 84–20 define eligibility for the health care
insurance plan in New Brunswick.
Residents are required to complete a Medicare application and
provide proof of Canadian citizenship, proof of residency, or a
valid Canadian immigration document. A resident is defined
as a person lawfully entitled to be, or to remain, in Canada,
who makes his or her home and is ordinarily present in New
Brunswick, but does not include a tourist, transient, or visitor
to the province.
As of March 31, 2015, there were 750,691 persons registered
in New Brunswick.
All persons entering or returning to New Brunswick (excluding
children adopted from outside Canada) have a waiting period
before becoming eligible for Medicare coverage. Coverage
commences on the first day of the third month following the
month of arrival. Exceptions are as follows:
■■ Dependents of Canadian Armed Forces personnel or their
spouses moving from within Canada to New Brunswick are
entitled to first day coverage under the program, provided
they are deemed to have established permanent residency
in New Brunswick.
■■ Immigrants or Canadian residents moving or returning
to New Brunswick from outside of Canada are entitled
to first day coverage, provided they are deemed to have
established permanent residency in the province. Proper
documentation is required (Immigration and Citizenship
documentation) and decisions on coverage and residency
are reviewed on a case-by-case basis.
Residents who were not eligible for Medicare coverage during
this reporting period included:
■■ regular members of the Canadian Armed Forces;
■■ non-Canadians who are issued certain types of Canadian
authorization permits (e.g., a Student Authorization).
Persons who are discharged or released in New Brunswick from
the Canadian Armed Forces, or a federal penitentiary, become
eligible for coverage on the date of their discharge or release.
An application must be completed and signed, and have proof
of Canadian citizenship, proof of residency and the official
date of release.
3.2 Other Categories of Individuals
Non-Canadians who may be issued an immigration permit
that would not normally entitle them to Medicare coverage are
eligible provided that they are legally married to, living in a
common-law relationship with or are a dependent of an eligible
New Brunswick resident and possess a valid immigration
permit. They are required to provide an updated immigration
document prior to the previous permit expiring.
4.0PORTABILITY
4.1 Minimum Waiting Period
A person is eligible for New Brunswick Medicare coverage on
the first day of the third month following the month permanent
residency has been established. The three month waiting
period is legislated under New Brunswick’s Medical Services
Payment Act. Refer to section 3.1 for exceptions.
4.2 Coverage During Temporary Absences
in Canada
The legislation that defines portability of health insurance
during temporary absences in Canada is the Medical Services
Payment Act, Regulation 84–20, sub-sections 3(4) and 3(5).
Medicare coverage may be extended upon request in the case
of temporary absences to:
■■ inmates at federal institutions;
■■ students in full-time attendance at an educational institution
■■ a family member who moves from another province to
■■ residents temporarily working in another jurisdiction; and
outside New Brunswick;
■■ temporary residents;
New Brunswick before other family members move;
■■ persons who have entered New Brunswick from another
province to further their education and who are eligible
to receive coverage under the medical services plan of that
province; and
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CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
■■ residents whose employment requires them to travel outside
the province.
CHAPTER 3: NEW BRUNSWICK
Students
Those in full-time attendance at a university or other approved
educational institution, who leave the province to further their
education in another province, will be granted coverage for
a 12 month period that is renewable, provided the following
terms are met:
■■ Medicare is contacted once every 12 months;
■■ permanent residency is not established outside New Brunswick;
and
■■ health coverage is not received elsewhere.
Residents
Residents temporarily employed in another province or territory,
are granted coverage for up to 12 months provided the following
terms are met:
■■ permanent residency is not established outside New Brunswick;
and
■■ health insurance coverage is not received elsewhere.
New Brunswick has formal agreements for reciprocal billing
arrangements of insured hospital services with all provinces
and territories. In addition, New Brunswick has reciprocal
agreements with all provinces, except Quebec, for the provision
of insured physician services. Services provided by Quebec
physicians to New Brunswick residents are paid at Quebec rates
provided the service delivered is insured in New Brunswick.
The majority of such claims are received directly from Quebec
physicians. Any claims submitted directly by a patient are reimbursed to the patient.
4.3 Coverage During Temporary Absences
Outside Canada
The legislation that defines portability of health insurance
during temporary absences outside Canada is the Medical
Services Payment Act, Regulation 84–20, subsections 3(4)
and 3(5).
Eligibility for temporarily absent New Brunswick residents is
determined in accordance with the Medical Services Payment Act
and regulations and the Interprovincial Agreement on Eligibility
and Portability.
Residents temporarily employed outside Canada are granted
coverage for 182 days. This may be extended up to 12 months
within a three year period upon approval from the Director of
Medicare Eligibility and Claims. Exceptions to this are Mobile
and Contract workers.
Coverage for any absence over 212 days for vacation purposes
requires approval from the Director of Medicare Eligibility
and Claims. This approval can only be for up to 12 months in
duration and will only be granted once every three years.
New Brunswick residents exceeding the 12 month extension
have to reapply for New Brunswick Medicare upon their return
to the province. In this instance, cases are reviewed on a case by
case basis. Depending on the circumstances, some cases may be
eligible for first day coverage while others who have been away
from the province slightly beyond the 12 month period may be
given a grace period.
Insured residents who receive insured emergency services
out-of-country are eligible to be reimbursed $100 per day
for in-patient stays and $50 per out-patient visit. The insured
resident is reimbursed for physician services associated with the
emergency treatment at New Brunswick rates. The difference
in rates is the patient’s responsibility.
Mobile Workers
Mobile Workers are residents whose employment requires
them to travel outside the province (e.g., pilots). The following
guidelines must be met to receive Mobile Worker designation:
■■ applications must be in writing;
■■ documentation is required as proof of Mobile Worker status
(e.g., letter from employer or contract confirming that
frequent travel is necessary outside the province; a letter from
the resident detailing their permanent residence as New
Brunswick and the frequency of their return to the province;
a copy of their New Brunswick driver’s license; if working
outside Canada, a copy of resident’s immigration documents
that allow them to work outside the country); and
■■ the worker must return to New Brunswick during their
off-time.
Mobile Worker status is assigned for a maximum of two years,
after which the resident must reapply and submit documentation
to confirm a continuation of Mobile Worker status.
The Interprovincial Agreement on Eligibility and Portability
is for within Canada and has no bearing on the individual
provinces handling of movement outside of Canada.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
53
CHAPTER 3: NEW BRUNSWICK
Contract Workers
Any New Brunswick resident accepting a contract out-of-country
must supply the following information and documentation:
■■ a letter of request from the New Brunswick resident with
their signature, detailing their absence, Medicare number,
address, departure and return dates, destination, forwarding
address, and reason for absence; and
■■ a copy of a contractual agreement between employee and
employer indicating start and end dates of employment.
Contract Worker status is assigned up to a maximum of two
years. Any further requests for contract worker status must be
forwarded to the Director of Medicare Eligibility and Claims
for approval on an individual basis.
Students
Those in full-time attendance at a university or other approved
educational institution in another country will be granted
coverage for a 12 month period that is renewable, provided they
comply with the following:
■■ proof of enrolment must be provided from the educational
institution on an annual basis;
■■ Medicare must be contacted once every 12 months;
■■ permanent residency cannot be established outside
New Brunswick; and
■■ health insurance coverage cannot be received elsewhere.
4.4 Prior Approval Requirement
If the above requirements are met, it is mandatory to request
prior approval from Medicare in order to receive coverage.
A physician, patient or family member may request prior
approval to receive these services outside the country,
accompanied by supporting documentation from a Canadian
specialist or specialists.
Out-of-country insured services that are not available in
Canada, are non-experimental, and receive prior approval
are paid in full. Often the amount payable is negotiated
with the provider by Europ Assistance — Global Corporate
Solutions on the province’s behalf.
Heamodialysis is exempt from the out-of-country coverage
policy. Patients are required to obtain prior approval and
Medicare will reimburse the resident at a rate equivalent
to the inter-provincial rate of $472 per session.
Prior approval is also required to refer patients to psychiatric
hospitals and addiction centres outside the province because
they are excluded from the Interprovincial Reciprocal Billing
Agreement. A request for prior approval must be received
by Medicare from the Addiction Services or Mental Health
branches of the Department.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
New Brunswick’s health care system delivers equitable,
quality care to the public it serves. New Brunswick does not
charge user fees for insured health services as defined by the
Canada Health Act.
Medicare may cover out-of-country services that are not
available in Canada on a pre-approval basis only. Residents
may opt to seek non-emergency out-of-country services;
however, they are responsible for assuming the total cost.
Access in a resident’s official language of choice is not a limiting
factor, regardless of where a resident receives services in
the province.
New Brunswick residents may be eligible for reimbursement
if they receive elective medical services outside the country,
provided the following requirements are met:
5.2 Physician Compensation
■■ the required service or equivalent, or an alternate service
must not be available in Canada;
■■ the service must be rendered in a hospital listed in the
current edition of the American Hospital Association
Guide to the Health Care Field (guide to United States
hospitals, health care systems, networks, alliances,
health organizations, agencies and providers);
■■ the service must be rendered by a medical doctor; and
■■ the service must be an accepted method of treatment
recognized by the medical community and be regarded as
scientifically proven in Canada. Experimental procedures
are not covered.
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CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
Payments to physicians and dentists are governed under the
Medical Services Payment Act, Regulations 84–20, 93–143
and 2002–53.
The methods used to compensate physicians for providing
insured health services in New Brunswick are fee-for-service,
salary and sessional, or alternate payment mechanisms that
may include a blended system.
CHAPTER 3: NEW BRUNSWICK
5.3 Payments to Hospitals
The legislative authorities governing payments to hospital
facilities in New Brunswick are the Hospital Act, which governs
the administration of hospitals, and the Hospital Services Act,
which governs the financing of hospitals. The Regional Health
Authorities Act provides for the delivery and administration of
health services in defined geographic areas within the province.
The Department mainly distributes available funding to New
Brunswick’s regional health authorities (RHAs) through a
Current Service Level approach. The funding base of the RHA
from the previous year is the starting point, to which approved
salary increases and a global inflator for non-wage items are
added. This applies to all clinical services provided by hospital facilities, as well as support services (e.g., administration,
food services, etc.). Funding for the Extra-Mural Program
(home care) is also part of the RHA base.
Funding for FacilicorpNB, a shared services agency that manages the information technology, materials management,
laundry and clinical engineering components of the hospital
facilities in New Brunswick, is also based on the Current
Service Level approach.
Any requests for funding for new programs or services are submitted to the Deputy Minister of Health for approval. Funding
for approved new programs or services is based on requirements
identified through discussions between Department of Health
and RHA staff. These amounts are added to the RHA funding
base once there is agreement on the funding requirements.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
New Brunswick recognizes the federal role regarding its
contributions under the Canada Health Transfer in public
documentation presented through legislative and administrative processes. Federal transfers are identified in the Main
Estimates document and in the Public Accounts of New
Brunswick. Both documents are published annually by the
New Brunswick government.
CANADA HEALTH ACT
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55
CHAPTER 3: NEW BRUNSWICK
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
748,352
748,406
748,570
749,613
750,691
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
57
56
59
60
60
1,616,340,008
1,721,356,342
1,736,939,230
1,771,731,561
1,876,686,329
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4. Number of private for-profit facilities
providing insured health services (#).1
0
0
0
0
0
5. Payments to private for-profit facilities
for insured health services ($).1
0
0
0
0
0
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4,537
3,925
4,820
5,175
4,476
44,337,432
38,410,486
48,373,187
56,033,200
44,805,445
44,444
32,310
60,927
52,858
55,412
14,186,848
11,455,683
21,213,988
19,086,912
20,236,157
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
245
242
274
209
150
607,147
808,783
202,669
254,241
239,512
1,805
1,285
1,080
1,004
882
798,355
857,130
286,912
286,584
354,378
1. There are no private for-profit facilities operating in New Brunswick.
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CHAPTER 3: NEW BRUNSWICK
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1,588
1,618
1,640
1,635
1,631
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of not participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($). 3
538,111,685
543,148,047
581,432,080
554,684,438
577,131,145
18.Total payments for services provided by
physicians paid through fee-for-service ($).
279,663,511
306,092,105
307,211,084
306,411,123
325,012,469
14.Number of participating physicians (#). 2
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
209,868
182,746
210,727
254,378
194,660
11,965,539
13,221,951
15,089,061
22,127,528
18,284,577
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
4,610
5,072
6,425
4,714
2,621
568,937
635,020
397,912
315,078
246,305
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
23.Number of participating dentists (#). 4
24.Number of services provided (#).
25.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
14
23
20
21
18
2,722
2,859
4,949
2,083
2,311
367,905
712,367
663,654
718,088
618,627
2. These are the number of physicians with an active physician status on March 31st of each year.
3. The total payment for all payment methods is a preliminary figure and includes budgeted amounts for alternate funding plans. Fee-for-service is for automated
fee-for-service only.
4. These are the number of dentists and oral maxillofacial surgeons (OMS) participating in New Brunswick’s Medical Services Plan during each fiscal year.
Out of the 100+ dentists and OMSs registered, these billed the Medical Services Plan.
CANADA HEALTH ACT
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QUEBEC
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
The Quebec Hospital Insurance Plan is administered by the
Ministère de la Santé et des Services Sociaux (MSSS) [the
Quebec Ministry of Health and Social Services].
Quebec’s health and drug insurance plans are administered
by the Régie de l’assurance maladie du Québec (the Régie),
a public body established by the provincial government that
reports to the Minister of Health and Social Services.
1.2 Reporting Relationship
The Public Administration Act (R.S.Q., c. A-6.01) sets forth
government criteria for preparing reports on the planning and
performance of public authorities, including the MSSS and
the Régie.
1.3 Audit of Accounts
The Quebec Hospital Insurance Plan and the Quebec health
and drug insurance plans are administered by the public
authorities on a non-profit basis. All books and accounts
are audited by the auditor general of the province.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
Insured in-patient services include the following: Standard
ward accommodation and meals; necessary nursing services;
routine surgical supplies; diagnostic services; use of operating
rooms, delivery rooms and anaesthetic facilities; medication;
prosthetic and orthotic devices that can be integrated with
the human body; biological products and related preparations;
use of radiotherapy and physiotherapy facilities; and services
delivered by hospital staff.
Out-patient services include the following: Clinical services for
psychiatric care; electroshock, insulin and behaviour therapies;
emergency care; minor surgery (day surgery); radiotherapy;
diagnostic services; physiotherapy; occupational therapy;
inhalation therapy, audiology, speech therapy and orthoptic
services; and other services or examinations required under
Quebec legislation.
Other insured services include the following: Mechanical,
hormonal or chemical contraception services; surgical
sterilization services (including tubal ligation or vasectomy);
reanastomosis of the fallopian tubes or vas deferens; and
extraction of a tooth or root when the patient’s health status
makes hospital services necessary.
The MSSS administers an ambulance transportation program
that is free of charge to persons aged 65 and older.
In addition to basic insured health services, the Régie also
covers optometric services for people who are under age 18 and
65 and over, and for last-resort financial assistance recipients;
dental care for children age 10 and under and last-resort
financial assistance recipients; and acrylic dental prostheses
for last-resort financial assistance recipients.
It also covers, for Quebec residents, as defined in the Health
Insurance Act (R.S.Q. c. A 29) who meet the eligibility
criteria for each program, prostheses, orthotics, orthopedic
appliances, walking and posture aids; hearing aids and assistive
listening devices; visual aids; external breast prostheses; ocular
prostheses; permanent ostomy appliances and compression
clothing for people with lymphedema.
With regard to drug insurance, since January 1, 1997, the Régie
has covered, in addition to recipients of last-resort financial
assistance and persons aged 65 and over, Quebec residents who
otherwise would not have access to a private drug insurance plan.
In 2014–2015, the drug insurance plan covered 3.5 million
insured persons.
2.2 Insured Physician Services
Services insured under this plan include medical and surgical
services that are provided by physicians participating in the
plan and are medically necessary.
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CHAPTER 3: QUEBEC
Family planning services set forth by legislation and provided
by a physician are insured, as are assisted reproduction services
set forth by regulation.
2.3 Insured Surgical-Dental Services
Services insured under this plan include maxillo-facial
surgery performed by dental surgeons and specialists in oral
and maxillo-facial surgery, in a prescribed hospital centre or
university institution.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital services include plastic surgery for purely
cosmetic purposes, a private or semi-private room at the
patient’s request, televisions, telephones, drugs and biological
products ordered after discharge from hospital, and services
for which the patient is covered under the Act respecting
industrial accidents and occupational diseases or other federal
or provincial legislation.
The following services, among others, are not insured:
any examination or service not related to a process of curing
or preventing illness; psychoanalysis of any kind, unless
such service is delivered in a facility maintained by an
institution authorized for such purpose by the Minister of
Health and Social Services; any service provided solely for
aesthetic purposes; any refractive surgery, except where there
is documented failure in respect of corrective lenses and
contact lenses for astigmatism of more than 3.00 diopters
or anisometropia of more than 5.00 diopters measured
from the cornea; any consultation by telecommunication or
by correspondence; any service delivered by a professional
to his or her spouse or children; any examination, expert
appraisal, testimony, certificate or other formality required
for legal purposes or by a person other than the one who
has received an insured service, except in certain cases; any
visit made for the sole purpose of obtaining the renewal of a
prescription; any examination, vaccination, immunization or
injection where the service is provided to a group or for certain
purposes; any service delivered by a professional on the basis
of an agreement or contract with an employer, association
or body; any adjustment of eyeglasses or contact lenses; any
surgical extraction of a tooth or dental fragment performed
by a physician, unless such a service is provided in a hospital
centre in certain cases; all acupuncture procedures; injection
of sclerosing substances and the examination performed at
that time; mammography used for detection purposes, unless
this service is required by medical prescription in a place
designated by the Minister to a recipient 35 years of age or
older, provided that the person has not been so examined
for one year; thermography, tomodensitometry, magnetic
resonance imaging and use of radionuclides in vivo in humans,
unless these services are delivered in a hospital centre;
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CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
ultrasonography, unless this service is delivered in a hospital
centre or, for obstetrical purposes, in a local community
service centre (CLSC) recognized for that purpose; optical
tomography of the eyeball and confocal scanning laser
ophthalmoscopy of the optic nerve, unless these services are
delivered in a facility maintained by an institution that operates
a hospital or are delivered in association with the delivery,
by intravitreal injection, of an antiangiogenic drug for the
treatment of age-related macular degeneration; any radiological
or anaesthetic service provided by a physician if required for
the provision of an uninsured service, with the exception of
a dental service provided in a hospital centre or, in the case
of radiology, if required by a person other than a physician or
dentist; any sex-reassignment surgery, unless it is provided on
the recommendation of a physician specializing in psychiatry
and is provided in a hospital centre recognized for this purpose;
and any services that are not related to pathology and that are
delivered by a physician to a patient between 18 and 65 years
of age, unless that individual is the holder of a claim booklet
for colour blindness or a refractive error, in order to provide
or renew a prescription for eyeglasses or contact lenses.
3.0UNIVERSALITY
3.1Eligibility
Registration with the hospital insurance plan is not required.
Registration with the Régie de l’assurance maladie du
Québec is sufficient to establish an individual’s eligibility.
Any individual residing or staying in Quebec as defined in
the Health Insurance Act must be registered with the Régie de
l’assurance maladie du Québec to be eligible for hospital services.
3.2 Other Categories of Individuals
Inmates in federal penitentiaries are not covered by the plan.
Certain categories of residents, notably permanent residents
under the Immigration Act and persons returning to live in
Canada, become eligible under the plan following a waiting
period of up to three months. Persons from another country
receiving last-resort financial assistance benefits are eligible
upon registration. Canadian Forces personnel and their family
members posted to Quebec from another Canadian province or
territory who have a status permitting them to settle there are
eligible on the date of their arrival. Members of the Canadian
Forces who have not acquired Quebec resident status, and
inmates of federal penitentiaries become eligible the day they
are discharged or released. Immediate coverage is provided for
certain seasonal workers, repatriated Canadians, persons from
outside Canada who are living in Quebec under an official
bursary or internship program of the Ministère de l’Éducation
(the Quebec Department of Education), persons from outside
Canada who are eligible under an agreement or accord reached
CHAPTER 3: QUEBEC
with a country or an international organization, and refugees.
Persons from outside Canada who have work permits and
are living in Quebec for the purpose of holding an office or
employment for a period of more than six months become
eligible for the plan following a waiting period.
4.0PORTABILITY
4.1 Minimum Waiting Period
Persons settling in Quebec after moving from another province
of Canada are entitled to coverage under the Quebec Health
Insurance Plan when they cease to be entitled to benefits from
their province of origin, provided they register with the Régie.
4.2 Coverage During Temporary Absences
in Canada
If living outside Quebec in another province or territory
for 183 days or more, and provided they notify the Régie of
this, students and full-time unpaid trainees may retain their
status as residents of Quebec: students for a maximum of four
consecutive calendar years, and full-time unpaid trainees for
a maximum of two consecutive calendar years.
This is also the case for persons living in another province or
territory who are temporarily employed or working on contract
there. Their resident status can be maintained for no more than
two consecutive calendar years.
Persons directly employed or working on contract outside
Quebec for a company or corporate body with its headquarters
or a place of business in Quebec, to which they report directly,
or persons employed by the federal government and posted
outside Quebec also retain their status as a resident of the
province. The same is true of persons who remain outside the
province for 183 days or more, but less than 12 months within
a calendar year, provided such an absence occurs only once
every seven years.
The costs of insured services provided by health professionals
in another province or territory of Canada are reimbursed the
amount actually paid or the rate that would have been paid
by the Régie for such services in Quebec, whichever is less.
However, Quebec has negotiated a permanent arrangement
with Ontario to pay Ottawa doctors at the Ontario fee rate
for specialized services that are not available in the Outaouais
region. This agreement came into effect on November 1, 1989.
The Régie covers the amount it would have paid for the same
services in Quebec, and the Agence de la santé et des services
sociaux de l’Outaouais (Outaouais health and social services
agency) pays the difference between the cost invoiced by
Ontario and the amount initially reimbursed by the Régie. A
similar agreement was signed in December 1991 between the
Centre de santé de Témiscaming (Temiscaming Health Centre)
and the North Bay Regional Health Centre.
Costs of hospital services provided in another province or
territory of Canada are paid in accordance with the terms
and conditions of the Hospital Reciprocal Billing Agreement
regarding hospital insurance agreed to by the provinces
and territories of Canada. These costs are paid either at the
established per diem for hospitalization in a standard ward or
in intensive care proposed by the host province and approved
by all the provinces and territories or, in cases of outpatient
services or expensive procedures, at the approved interprovincial
rates. Insured persons who leave Quebec to settle in another
province or territory of Canada are covered for up to three
months after leaving the province.
4.3 Coverage During Temporary Absences
Outside Canada
Students, unpaid trainees, Quebec government officials posted
abroad and employees of non-profit organizations working in
international aid or co-operation programs recognized by the
Minister of Health and Social Services must contact the Régie
to determine their eligibility. If the Régie grants them special
status, they receive full reimbursement for hospital costs in
case of emergency or sudden illness, and are reimbursed up
to 75 percent in other cases.
As of September 1, 1996, hospital services provided outside
Quebec in case of emergency or sudden illness for persons
employed directly by a company or corporate body with
its headquarters or a place of business in Quebec to which
they report directly, or for persons employed by the federal
government and posted outside Quebec, are reimbursed in full
by the Régie, and reimbursed up to 75 percent in other cases.
For residents who receive insured services in a hospital outside
Canada, the Régie reimburses the cost of such services in case of
emergency or sudden illness to a maximum of C$100 per day if
the patient was hospitalized (including in the case of day surgery)
or to a maximum of C$50 per day for outpatient services.
However, hemodialysis treatments are covered to a maximum
of C$220 per treatment, including medications, whether the
patient is hospitalized or not. In these cases, the Régie covers
the associated professional services at the lowest cost, either the
amount actually paid or what would have been paid by the Régie
for the same services in Quebec. The services must be delivered
in a hospital, or hospital centre, recognized and accredited by the
appropriate authorities. No reimbursements are made for nursing
homes, spas or similar establishments, or for any services that are
experimental in nature.
Costs for insured services provided by physicians, dentists,
maxillo-facial surgeons and optometrists are reimbursed at
the rate that would have been paid by the Régie to a health
professional recognized in Quebec, up to the amount of the
expenses actually incurred. When they are delivered abroad,
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CHAPTER 3: QUEBEC
all professional services insured by the Quebec Health
Insurance Plan are reimbursed at the Quebec rate, usually
in Canadian funds.
An insured person who moves permanently from Quebec to
another country ceases to be a recipient on the day of departure.
Residents of Quebec who are working or studying abroad are
covered by that country’s plan when the stay falls under a social
security agreement reached between the Minister of Health
and Social Services and the country in question.
4.4 Prior Approval Requirement
To receive full reimbursement for hospital services elsewhere
in Canada or in another country, that are not covered under
agreements, a written request signed by two physicians with
expertise in the field of pathology of the person on whose
behalf the request is made must first be sent to the Régie. The
request must describe the specialized services required by the
insured person, must attest to the unavailability of said services
in Quebec or Canada, and must contain information about
the treating physician and the address of the hospital where
the services would be provided. Following an evaluation of
the request by the Régie, authorization to receive the services
is either given or denied. No authorization will be given if the
medical service in question is available in Quebec or if it is
an experimental service.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
Everyone has the right to receive adequate health care services
without any kind of discrimination. There is no extra-billing
by Quebec physicians.
On March 31, 2014, Quebec had 141 facilities operating as
hospital centres for a clientele suffering from acute, general and
specialized or psychiatric illnesses. On that date, 21,462 beds
were allotted to these facilities. In these centres, according to the
most recent available data, from April 1, 2013, to March 31, 2014,
Quebec hospital institutions had 784,596 admissions, which
accounted for 6,691,464 patient days. In the same period, there
were 388,115 registrations for day surgeries.
Since 2003, the Quebec health care system has been based
on local services networks covering the entire province.
At the core of each of these local networks are the Health and
Social Services Centres (CSSS). The centres are the result of
the merger of public institutions whose mission was to provide
local community service centre (CLSC) services, residential
and long-term care services (CHSLD) and, in most cases,
neighbourhood hospital services. CSSSs must also provide the
people in their territory with access to other medical services,
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general and specialized hospital services, and social services. To
do so, they must enter into service agreements with other health
sector organizations. The linking of services within a territory
forms the local services network. Thus, the aim of integrated
local health and social services networks is to make all the
stakeholders in a given territory collectively responsible for
the health and well-being of the people in that territory.
Family medicine groups (FMGs) were established in
2003–2004. A FMG is a group of doctors working as a
team and in close collaboration with nurses and other CSSS
professionals from CSSSs to provide services ranging from
disease prevention, health assessment and patient monitoring,
as well as diagnosis and treatment of acute and chronic
problems. Their services include medical consultations with
and without an appointment, seven days a week, and an
adapted response to people whose health status requires special
arrangements for access to services. As of March 31, 2015,
there were 262 accredited FMGs and 53 network-clinics in
Quebec. Forty-five of the network-clinics are also FMGs.
5.2 Physician Compensation
Physicians are remunerated in accordance with the negotiated
fee schedule. The Minister may enter into an agreement with
the organizations representing any class of health professional.
This agreement may prescribe a different rate of compensation
for medical services in a territory where the number of
professionals is considered insufficient.
While the majority of physicians practise within the provincial
plan, Quebec allows two other options: professionals who
withdraw from the plan and practise outside the plan, but
agree to be remunerated according to the provincial fee
schedule; and non-participating professionals who practise
outside the plan, with no reimbursement from the Régie
going to either them or their patients.
According to the most recent data available, in 2014–2015,
the Régie paid an estimated $6.8 billion for professional
services provided to Quebec residents. Professional services
(including reimbursements to insured persons and payments
to professionals) received outside Quebec were estimated
at $41.4 million.
5.3 Payments to Hospitals
The Minister of Health and Social Services funds hospitals
through payments directly related to the cost of the insured
services provided.
The payments made in 2014–2015 to institutions operating as
hospital centres for insured health services provided to residents
of Quebec totalled nearly $11.6 billion. Payments to hospital
centres in other provinces or outside Canada for hospital
services totalled approximately $217.97 million.
ONTARIO
INTRODUCTION
1.2 Reporting Relationship
Ontario has one of the largest and most complex publiclyfunded health care systems in the world. Administered by
the province’s Ministry of Health and Long-Term Care
(MOHLTC), Ontario’s health care system was supported by
over $50.0 billion (including capital) in spending for 2014–2015.
The Health Insurance Act stipulates that the Minister of Health
and Long-Term Care is responsible for the administration and
operation of OHIP, and is Ontario’s public authority for the
purposes of the Canada Health Act.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
Ontario Health Care and Health Care Planning
The Ontario Health Insurance Plan (OHIP) is administered
on a non-profit basis by the Ministry of Health and LongTerm Care (MOHLTC). OHIP was established in 1972 and
is continued under the Health Insurance Act, Revised Statutes
of Ontario, 1990, c. H-6, to provide insurance in respect of
the cost of insured services provided to Ontario residents
(as defined in the Health Insurance Act) in hospitals and health
facilities, and by physicians and other health care practitioners.
The MOHLTC provides services to the public through
programs such as health insurance, drug benefits, assistive
devices, forensic mental health and supportive housing,
long‑term care, home care, community and public health,
and health promotion and disease prevention. It also regulates
hospitals and nursing homes, operates medical laboratories,
and coordinates emergency health services.
Local Health Integration Networks (LHINs) were established
under the Local Health System Integration Act, 2006 (LHSIA) to
help improve Ontarians’ health through better access to highquality health services, coordinated health care, and effective
and efficient management of the health system at the local level.
Since April 1, 2007, the LHINs have had responsibility for
funding, planning and integrating health care services at the
local level. This includes services delivered by hospitals, community care access centres, long-term care homes, community
health centres, community support services, and mental health
and addictions agencies.
The Local Health System Integration Act, 2006 (LHSIA) requires
each LHIN to prepare an annual report on its affairs and operations for the previous fiscal year. The Government of Ontario’s
Agency Establishment and Accountability Directive requires
that every Ontario operational service agency (including
LHINs) prepare an annual report. The Minister is required
to table the reports in the Legislative Assembly of Ontario.
MOHLTC has a performance agreement with each LHIN that
includes obligations, measures and targets for the networks.
The agreements also include the funding allocations by sector,
for example, long-term care homes and hospitals. LHSIA
provides the LHINs with the authority to fund defined health
service providers and to enter into service accountability
agreements with health service providers.
1.3 Audit of Accounts
Every year the Auditor General of Ontario reports on the
results of his examination of government resources and administration. The Auditor General’s report is tabled by the Speaker
of the Legislative Assembly, usually in the fall, at which time
it becomes available to the public. Audit reports on select areas
of the MOHLTC chosen for review by the Auditor General
are included within this annual report, the last of which was
released on December 9, 2014.
MOHLTC’s accounts and transactions are published annually in the Public Accounts of Ontario. The 2014–2015
Public Accounts of Ontario were tabled and released on
September 28, 2015.
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CHAPTER 3: ONTARIO
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
Insured in-patient and out-patient hospital services in
Ontario are prescribed under the Health Insurance Act, and
Regulation 552 under the Act.
Insured in-patient hospital services include medically required:
use of operating rooms, obstetrical delivery rooms and
anaesthetic facilities; necessary nursing services; laboratory,
radiological and other diagnostic procedures together with
the necessary interpretations for the purpose of maintaining
health, preventing disease and assisting in the diagnosis and
treatment of any injury, illness or disability; drugs, biologicals
and related preparations; and accommodation and meals at the
standard ward level.
Insured out-patient services include medically required: laboratory, radiological and other diagnostic procedures; use of
radiotherapy, occupational therapy, physiotherapy and speech
therapy facilities, where available; use of diet counselling
services; use of the operating room and anaesthetic facilities;
surgical supplies; necessary nursing service; supply of drugs,
biologicals, and related preparations (subject to some exceptions); certain other specified services such as the provision
of equipment, radiotherapy and occupational medication to
haemophiliac patients for use at home; and certain specified
home-administered drugs.
Hospital services are not specifically listed in Regulation 552
in the Health Insurance Act, rather, the Regulation lists broad
categories of services. This permits the Regulation to cover new
medical and technological advances as they become accepted
standards of practice.
Adding a new broad category of hospital services to the list of
insured services covered by the Ontario Health Insurance Plan
(OHIP) requires a regulatory change. Regulatory changes are
approved by Cabinet and generally there is a public consultation
process by way of Ontario’s Regulatory Registry.
No regulation changes to add hospital services were completed
in fiscal year 2014–2015.
2.2 Insured Physician Services
Insured physician services are prescribed under the
Health Insurance Act and regulations under the Act.
Under Regulation 552 to the Health Insurance Act, a service provided by a physician in Ontario is an insured service
if it is medically necessary; referred to in the Schedule of
Benefits — Physician Services; and rendered in such circumstances or under such conditions as specified in the Schedule
of Benefits — Physician Services. Physicians provide medical,
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surgical and diagnostic services, including primary health
care services. Services are provided in a variety of settings,
including: private physician offices, community health centres,
hospitals, mental health facilities, licensed independent health
facilities, and long-term care homes.
In general terms, insured physician services include: diagnosis
and treatment of medical disabilities and conditions; medical
examinations and tests; surgical procedures; maternity care;
anaesthesia; radiology and laboratory services in approved
facilities; and immunizations, injections and tests.
Physicians must be registered to practice medicine in Ontario
by the College of Physicians and Surgeons of Ontario, and be
located in Ontario when rendering the service.
During 2014–2015, most physicians submitted claims for all
insured services rendered to insured persons directly to OHIP,
and a limited number billed the insured person. Physicians who
do not bill OHIP directly are commonly referred to as having
opted out of the Plan. When a physician has opted out of the
Plan the physician bills the patient not exceeding the amount
payable for the service under the Schedule of Benefits (this was
permitted on a grandparented basis following proclamation
of the Commitment to the Future of Medicare Act in 2004).
The patient then recoups that amount from the Plan.
There were approximately 29,380 physicians who submitted
claims to OHIP in 2014–2015. This figure includes physicians
submitting both fee-for-service claims and physicians included
in an alternative payment plan who submitted tracking or
shadow-billed claims. In 2014–2015, there were 24 opted-out
physicians in Ontario.
The Schedule of Benefits — Physician Services is regularly
reviewed and revised to reflect current medical practice and
new technologies. New services may be added, existing services
revised, or obsolete services removed through regulatory
amendment. This process involves consultation with the
Ontario Medical Association.
In 2014–2015, in order to achieve savings, there were changes
made to the Schedule of Benefits — Physician Services.
These changes were effective February 1, 2015.
2.3 Insured Surgical-Dental Services
In accordance with the Canada Health Act, certain surgicaldental services are prescribed as insured services under
Regulation 552 in the Health Insurance Act and listed in
the Schedule of Benefits — Dental Services. The Health
Insurance Act authorizes OHIP to pay for a limited number of
procedures when the procedure is medically necessary, and it
is medically necessary that the insured services be performed
in a public hospital graded under the Public Hospitals Act
as Group A, B, C or D, by a dental surgeon who has been
appointed to the dental staff of the public hospital.
CHAPTER 3: ONTARIO
Generally, insured dental services include: oral and maxillo-facial
surgery that normally would be required to be performed in a
hospital; root resection and apical curettage procedures when
performed in association with other insured dental procedures;
and dental extractions when performed in a hospital for the
safety of high risk patients and if prior approval is obtained from
the Ministry of Health and Long-Term Care (MOHLTC).
With respect to insured surgical-dental services, MOHLTC
negotiates changes to the Schedule of Benefits — Dental
Services with the Ontario Dental Association. The MOHLTC
and the Ontario Dental Association agreed on a multi-year
funding agreement for dental services, which became effective
on April 1, 2002. The existing Schedule of Benefits — Dental
Services remains in effect and no new services were added to
the Schedule during the 2014–2015 fiscal year.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital services include but are not limited to:
private or semi-private accommodation unless prescribed by a
physician, oral-maxillofacial surgeon or midwife; telephones
and televisions; charges for certain private-duty nursing; and
provision of medications for patients to take home from hospital, with prescribed exceptions.
Section 24 of Regulation 552 details some specified physician
and supporting services that are not insured services.
Uninsured physician services include: services that are not
medically necessary; services not listed in the Schedule of
Benefits — Physician Services; and services that are excluded
from insured services under Section 24 of Regulation 552.
Dental services provided in dentists’ offices are not insured
and payment is the responsibility of the individual patient.
Dental services not specifically listed in the Dental Schedule
are also not insured including such services as dental
implants, prosthetic restorations (fixed bridges and dentures) for the replacement of teeth, orthodontic treatment,
fillings and crowns.
Complaints regarding charges for services, such as block fees or
enhanced medical goods or services, are investigated under the
Commitment to the Future of Medicare Act (CFMA) Program.
Investigations are opened to determine whether any patient was
charged for an insured service; this would include whether a
block fee included charges for insured service, or if a charge for
an enhanced service was in fact for an uninsured service. If it
is found that a patient was charged for an insured service, the
MOHLTC ensures that patients are reimbursed and providers
are educated on the prohibitions in the CFMA.
3.0UNIVERSALITY
3.1Eligibility
Section 11 of the Health Insurance Act specifies that every
person who is a resident of Ontario is entitled to become an
insured person under the Ontario Health Insurance Plan
(OHIP) upon application. In order to be considered an Ontario
resident, Regulation 552 under the Health Insurance Act, with a
few exceptions that are noted in the Regulation, requires that
a person must:
■■ hold Canadian citizenship or an immigration status as
prescribed in Regulation 552;
■■ make his or her primary place of residence in Ontario;
■■ subject to some limited exceptions, be physically present in
Ontario for at least 153 days in any 12-month period; and
■■ for most new and returning residents, be physically present
in Ontario for 153 of the first 183 days following the date
residence is established in Ontario, for example, a person
cannot be away from the province for more than 30 days
in the first six months of residency.
Individuals who are not eligible for OHIP coverage are those
who do not meet the definition of a resident, such as tourists,
transients, visitors to the province and those who do not hold
immigration or other similar status. Services that a person
is entitled to receive under federal legislation are not insured
services, for example those provided to federal penitentiary
inmates and Canadian Forces members. Services that a person
is entitled to receive under the Workplace Safety and Insurance Act
are not insured services in Ontario.
When it is determined that a person is not eligible, or is no
longer eligible, for OHIP coverage, a request may be made to
the Ministry of Health and Long-Term Care (MOHLTC) to
review the decision. Anyone may request that the MOHLTC
review the denial of their OHIP eligibility by making a request
in writing to the OHIP Eligibility Review Committee. Those
who are not satisfied with the decision regarding their OHIP
eligibility may request an appeal of their case by the Health
Services Appeal and Review Board.
MOHLTC is the sole payer for OHIP insured physician, hospital and hospital surgical-dental services. An eligible Ontario
resident may not obtain any benefits from another insurance
plan for the cost of any insured service that is covered by OHIP
(with the exception of during the OHIP waiting period).
Persons who were previously ineligible for OHIP coverage
but whose status and/or residency situation has changed may
be eligible upon application, subject to the requirements of
Regulation 552.
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3.2 Other Categories of Individuals
MOHLTC provides health insurance coverage to a limited
number of specified categories of residents of Ontario, other
than Canadian citizens and permanent residents or landed
immigrants.
These residents are required to provide acceptable documentation
to support their residence in Ontario and their identity in the
same manner as Canadian citizens and permanent resident or
landed immigrant applicants.
The individuals listed below who are residents in Ontario
may be eligible for OHIP coverage in accordance with
Regulation 552 of the Health Insurance Act. Individuals are
required to apply in person to ServiceOntario, which has the
government-wide mandate for the delivery of front-facing
services to the residents of Ontario, including the issuance
of the Ontario Photo Health Card.
Applicants for Permanent Residence: These are persons who
have submitted an application for Permanent Resident status
to Citizenship and Immigration Canada (CIC) and CIC has
confirmed that the person meets the eligibility requirements
to apply for permanent residence in Canada and that the
application has not yet been denied.
Protected Persons: These are persons who are determined to be
Protected Persons under the terms of the federal Immigration
and Refugee Protection Act. Members of this group are provided
with immediate OHIP coverage.
Holders of Temporary Resident Permits: A Temporary
Resident Permit is issued to an individual by CIC when there
are compelling reasons to admit an individual into Canada who
would otherwise be inadmissible under the federal Immigration
and Refugee Protection Act. Each Temporary Resident Permit
has a case type or numerical designation on the permit that
indicates the circumstances allowing the individual entry into
Canada. Individuals who hold a permit with a case type of
86, 87, 88, 89, 90, 91, 92, 93, 94, 95 or 80 (if for adoption) are
eligible for OHIP coverage. Individuals who hold a permit with
a case type of 80 (except for adoption), 81, 84, 85 and 96 are not
eligible for OHIP coverage.
Clergy, Foreign Workers and their Accompanying Family
Members: An eligible foreign clergy is a person who is
sponsored by a religious organization or denomination if the
member has finalized an agreement to minister to a religious
congregation or group in Ontario for at least six months,
as long as the member is legally entitled to stay in Canada.
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A foreign worker is eligible for OHIP if the individual has been
issued a Work Permit or other document by CIC that permits
the person to work in Canada, and if the person also has a
formal agreement in place to work full-time for an employer in
Ontario. The work permit or other document issued by CIC,
or a letter provided by the employer, must set out the employer’s
name, state the person’s occupation with the employer, and state
that the person will be working for the employer for no less
than six consecutive months.
A spouse and/or dependant (under 22 years of age; or 22 years of
age or older if dependent due to a mental or physical disability)
of an eligible foreign member of the clergy or an eligible foreign
worker is also eligible for OHIP coverage as long as the spouse
or dependant is legally entitled to stay in Canada.
Live-in Caregivers: Eligible live-in caregivers are persons who
hold a valid Work Permit under the Live-in Caregiver Program
(LCP) administered by the Government of Canada. The Work
Permit for LCP workers does not have to list the three specific
employment conditions required for all other foreign workers.
Applicants for Canadian Citizenship: These individuals
are eligible for OHIP coverage if they have submitted an
application for Canadian citizenship under section 5.1 of the
federal Citizenship Act, even if the application has not yet been
approved, provided that CIC has confirmed that the person
meets the eligibility requirements to apply for citizenship under
that section and the application has not yet been denied.
Children Born Out-of-Country: A child born to an OHIPeligible woman who was transferred from Ontario to receive
insured health services that were pre-approved for payment
by OHIP is eligible for immediate OHIP coverage provided
that the mother was pregnant at the time of departure
from Ontario.
Seasonal Agricultural Farm Workers are persons who have
a Work Permit issued under the Seasonal Agricultural Worker
Program administered by the Government of Canada. Due to
the special nature of their employment, migrant farm workers
do not have to meet any other residency requirement and are
provided with immediate OHIP coverage.
3.3Premiums
No premiums are required to obtain OHIP coverage. There
is an Ontario Health Premium that is collected through the
provincial income tax system but it is not connected to OHIP
registration or eligibility in any way. Responsibility for the
administration of the Ontario Health Premium lies with the
Ontario Ministry of Finance.
CHAPTER 3: ONTARIO
4.0PORTABILITY
4.1 Minimum Waiting Period
In accordance with section 5 of Regulation 552 under the
Health Insurance Act, individuals who move to Ontario are
typically entitled to Ontario Health Insurance Plan (OHIP)
coverage three months after establishing residency in the
province unless listed as an exception in sections 6, 6.1,
6.2, or 6.3 of Regulation 552, or sub section 11(2.1) of the
Health Insurance Act.
Assessment of whether or not an individual is subject to the
waiting period occurs at the time of their application for OHIP
coverage. Examples of those who are exempt from the three
month waiting period include newborn babies, eligible military
family members, and insured residents from another province
or territory who move to Ontario and immediately become
residents of an approved long-term care home in Ontario.
In accordance with Regulation 552 under the Health Insurance Act
and as provided for in the Interprovincial Agreement on
Eligibility and Portability, persons who permanently move to
Ontario from another Canadian province or territory where they
are insured will typically be eligible for OHIP coverage after the
last day of the second full month following the date residency is
established, in other words, an interprovincial waiting period.
4.2 Coverage During Temporary Absences
in Canada
Insured out-of-province services are prescribed under sections 28,
28.0.1, and 29 of Regulation 552 of the Health Insurance Act.
Ontario adheres to the terms of the Interprovincial Agreement
on Eligibility and Portability; therefore, insured residents
who are temporarily outside of Ontario can use their Ontario
health cards to obtain insured physician (except in Quebec)
and hospital services.
An insured person who leaves Ontario temporarily to travel
within Canada, without establishing residency in another
province or territory, may continue to be covered by OHIP
for a period of up to 12 months.
An insured person who temporarily seeks or accepts employment
in another province or territory may continue to be covered by
OHIP for a period of up to 12 months. If the individual plans
to remain outside Ontario beyond the 12 month maximum,
he or she should apply for coverage in the province or territory
where that person has been working or seeking work.
Insured students who are temporarily absent from Ontario, but
remain within Canada, may be eligible for continuous health
insurance coverage for the duration of their full-time studies,
provided they do not establish permanent residency elsewhere
during this period. To ensure that they maintain continuous
OHIP eligibility, a student should provide the Ministry of
Health and Long-Term Care (MOHLTC) with documentation
or information from their educational institution confirming
registration as a full-time student. Insured family members
(spouses and dependants) of students who are studying in
another province or territory are also eligible for continuous
OHIP eligibility while accompanying students for the duration
of their studies.
In accordance with Regulation 552 of the Health Insurance Act,
most insured residents who want to travel, work or study
outside Ontario, but within Canada, and maintain OHIP
coverage, must have resided in Ontario for at least 153 days
in the last 12-month period immediately prior to departure
from Ontario.
Ontario participates in Reciprocal Hospital Billing Agreements
with all other provinces and territories for insured in-patient
and out-patient hospital services. Rates are set and approved
annually by the Interprovincial Health Insurance Agreements
Coordinating Committee. Payment for in-patient services is at
the hospital’s approved in-patient per diem rate. Payment for
out-patient services is at the standard approved out-patient rate.
Ontario pays the standard out-patient charges set out by the
Interprovincial Health Insurance Agreements Coordinating
Committee. Ontario is also party to the Physicians’ Reciprocal
Billing Agreements with all other provinces and territories,
except Quebec (which has not signed a reciprocal physician
agreement with any other province or territory). Ontario residents who may be required to pay for insured physician services
in another province or territory can submit their receipts to
MOHLTC for payment at Ontario rates.
4.3 Coverage During Temporary Absences
Outside Canada
Residents may be temporarily outside of Canada for a total
of 212 days in any 12 month period and still maintain
OHIP coverage as long as their primary place of residence
remains Ontario.
Extended Absences:
Health insurance coverage for insured Ontario residents during
extended absences (longer than 212 days) outside Canada is
governed by Regulation 552 of the Health Insurance Act.
The MOHLTC requests that residents apply to MOHLTC
to confirm this coverage before their departure and provide
documents explaining the reason for their absence.
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CHAPTER 3: ONTARIO
In accordance with regulations and MOHLTC policy, most
applicants must also have been residents in Ontario for at least
153 days in each of the two consecutive 12 month periods
before their expected date of departure.
The length of time that a person can receive continuous Ontario
health insurance coverage during an extended absence outside Canada varies depending on the reason for the absence
as follows:
Reason
OHIP Coverage
Study
Duration of full-time academic studies
(unlimited)
Work
Five-year terms (specific residency
requirements must be met for 2 years
between absences)
Charitable Worker
Vacation/Other
Five-year terms (specific residency
requirements must be met for 2 years
between absences)
Two-year terms (specific residency
requirements must be met for 5 years
between absences)
During 2014–2015, out-of-country emergency, medically
necessary, out-of-country physician services were reimbursed
at the Ontario rates set out in Regulation 552 under the
Health Insurance Act or the amount billed, whichever was less.
4.4 Prior Approval Requirement
As set out in Regulation 552 under the Health Insurance Act,
written prior approval from MOHLTC is required for payment
for non-emergency health services provided outside of Canada
prior to the medical services being rendered.
The prior approval application which includes written
confirmation from the referring Ontario physician must
establish that the services or tests are:
■■ medically necessary;
■■ performed at an out-of-country licensed hospital or health
facility (as defined in the Regulations);
■■ not experimental or for the purposes of research or a survey;
■■ generally accepted by the medical profession in Ontario as
appropriate for a person in the same medical circumstances
as the insured person; and either
−− not performed in Ontario by an identical or equivalent
Certain family members may also qualify for continuous OHIP
coverage while accompanying the primary applicant on an
extended absence outside Canada.
Out-of-Country Coverage for Ontario Residents who
are Temporarily Absent
Payment of out-of-country services for Ontarians who are
temporarily absent from Canada, such as for travelling, are
captured under Regulation 552 of the Health Insurance Act.
Out-of-country costs are for hospital and health facility services
required to treat a condition that is acute and unexpected, arose
outside of Canada, and requires immediate treatment. They
are reimbursed at rates set out in Regulation 552 under the
Health Insurance Act:
■■ a maximum $400 (CAD) for in-patient services for a
higher level of care as described in the Regulations and
$200 (CAD) for any other level of care;
■■ a maximum $50 (CAD) for out-patient services (except
dialysis); and
■■ a maximum of $210 (CAD) for renal dialysis.
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procedure or
−− performed in Ontario but the insured person must travel
outside of Canada to avoid delay that would result in
death or medically significant irreversible tissue damage.
Except in an emergency, written prior approval of payment
must be granted by the General Manager before any of the
health services are rendered.
Requests for prior approval of funding require the endorsement
of a physician who is a specialist in the type of services for
which prior approval has been requested. This requirement
does not apply to emergency services and services that are
within a general practitioner’s scope of practice.
There are also other specified requirements in section 28.4
of Regulation 552 depending on the nature of the service for
which funding is requested.
Funding requirements for non-emergency laboratory tests
performed outside Canada are described in section 28.5 of
Regulation 552 of the Health Insurance Act.
During 2014–2015 there was no formal prior approval required
for services provided to eligible Ontario residents outside the
province, but within Canada, if the insured service is covered
under the Reciprocal Hospital Billing Agreements.
CHAPTER 3: ONTARIO
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
All insured hospital, physician and surgical-dental services are
available to Ontario residents on uniform terms and conditions.
All insured persons are entitled to all insured physician,
surgical-dental and hospital services, as defined in the Health
Insurance Act and regulations.
Access to insured services is protected under Part II of the
Commitment to the Future of Medicare Act (CFMA), “Health
Services Accessibility.” The CFMA prohibits any person or
any entity from charging or accepting payment or other benefit
for an insured service rendered to an insured person except as
permitted in the CFMA. In addition, the CFMA prohibits
physicians, practitioners and hospitals from refusing to provide
an insured service if an insured person chooses not to pay a
“block fee” for an uninsured service. The CFMA further prohibits any person or entity from paying, conferring, charging, or
accepting a payment or other benefit in exchange for preferred
access for an insured person to an insured service.
The Ministry of Health and Long-Term Care (MOHLTC)
investigates all possible contraventions of Part II of the CFMA
that come to its attention. For situations in which it is found
that a patient has been extra-billed, the MOHLTC ensures
that the amount is repaid to that patient.
Health Card Validation (HCV) assists health care providers
with access to information requested for claims payment. HCV
allows the provider to determine the point-in-time status of a
patient’s Ontario health number (and version code) indicating
eligibility or ineligibility for provincially funded health care
services, thereby reducing claim rejects. A health care provider
may subscribe for validation services if they have a valid
and active billing number as assigned by the MOHLTC. If
patients require access to insured services and do not have a
valid health card in their possession, upon obtaining patient
consent, the provider may obtain the necessary information by
utilizing the accelerated health number release service provided
by ServiceOntario’s Health Number Look Up service which
is offered 24 hours a day, 365 days per year to physicians or
hospitals registered for this service.
Acute care priority services are designated, highly specialized,
hospital-based services that deal with life-threatening
conditions such as organ transplants, cancer surgery and
treatments, and neuroservices. These services are often
high-cost and are rapidly growing, which has made access a
concern. Generally, these services are managed provincially,
on a time-limited basis.
Acute care priority services include:
■■ selected cardiovascular services;
■■ selected cancer services;
■■ chronic kidney disease services;
■■ critical care services; and
■■ organ and tissue donation and transplantation.
Primary Health Care: During 2014–2015, consistent with
the government direction outlined in Patients First: Action
Plan for Healthcare 2015, Ontario continued to align its new
and existing primary health care delivery models to help
improve and expand access to primary health care physician services for all Ontarians. The various primary health
care physician compensation models encourage access to
comprehensive primary health care services for Ontario as a
whole, as well as for targeted population groups and remote
under-serviced communities.
Health Care Connect (HCC): HCC helps Ontarians who are
without a primary health care provider (family doctor or nurse
practitioner) to find one. Insured persons without a primary
health care provider who register with HCC may be referred
to a family doctor or a nurse practitioner if there is an available
provider who is accepting new patients in their community.
During 2014–2015, MOHLTC continued to administer
various initiatives in order to improve access to health care
services across the province. Ontario has taken steps to stabilize
physician supply through evidence-informed planning, and has
enhanced the retention and distribution of physicians in the
province by taking such measures as:
■■ stabilizing the significant expansion in medical education
since 2003;
■■ supporting rural and remote clinical education opportunities
for medical students;
■■ supporting the Northern Ontario School of Medicine;
■■ supporting training and assessment programs for
International Medical Graduates and other qualified
physicians who do not meet certain requirements for
practice in Ontario; and
■■ supporting the HealthForceOntario Marketing and
Recruitment Agency to help recruit and retain health care
professionals in Ontario communities that need them.
There are a number of existing initiatives to improve
access across Ontario, including but not limited to the
HealthForceOntario Northern and Rural Recruitment and
Retention Initiative (NRRRI), the Northern Physician
Retention Initiative (NPRI), and the Northern Health Travel
Grant (NHTG) Program.
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CHAPTER 3: ONTARIO
■■ Northern and Rural Recruitment and Retention
Initiative (NRRRI): The NRRRI supports the recruitment and retention of physicians in rural and northern
communities. The NRRRI provides financial recruitment
incentives to physicians who establish a full-time practice
in an eligible community. Community eligibility for the
NRRRI is based on a Rurality Index for Ontario score
of 40 or more. Also eligible are the five Northern Ontario
Census Urban Referral Centre census metropolitan areas
(Thunder Bay, Sudbury, North Bay, Sault Ste. Marie
and Timmins).
■■ Northern Physician Retention Initiative (NPRI): The
NPRI provides physicians who have completed a minimum
of four years of continuous full-time practice in Northern
Ontario with a $7,000 retention incentive paid at the end of
each fiscal year in which they continue to practice full-time
in Northern Ontario. NPRI supports retention of physicians
in Northern Ontario and encourages them to maintain
active hospital privileges. Northern Ontario is defined as
the districts of Algoma, Cochrane, Kenora, Manitoulin,
Nipissing, Parry Sound, Muskoka, Rainy River, Sudbury,
Thunder Bay and Timiskaming.
■■ Northern Health Travel Grant (NHTG) Program:
The NHTG Program helps defray travel-related costs
for residents of Northern Ontario who must travel long
distances to access insured medical specialist services, or
designated health care facility-based procedures that are
not locally available, within a radius of 100km. The NHTG
Program also promotes using specialist services located in
Northern Ontario, which encourages more specialists to
practice and remain in the north.
5.2 Physician Compensation
Physicians are paid for the services they provide through a
number of mechanisms. Some physician payments are provided
through fee-for-service arrangements. Remuneration is based
on the Schedule of Benefits under the Health Insurance Act.
Other physician payment models include Primary Health
Care Models (such as blended capitation models), Alternate
Payment Plans, and new funding arrangements for physicians
in Academic Health Science Centres.
In 2014–2015, 97 percent of General Practitioners received
fee-for-service payments from OHIP, but fewer than
30 percent of them were paid solely on a fee-for-service
basis. The majority (70 percent) of primary care physicians in
Ontario received funding through one of the primary health
models: Comprehensive Care (CCM), Family Health Group
(FHG), Family Health Network (FHN), Family Health
Organization (FHO), Community Health Centres (CHC),
Rural and Northern Physician Group Agreement (RNPGA),
Group Health Centre (GHC), Blended Salary Model (BSM),
and specialized agreements.
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Family Health Teams (FHTs) are independent, non-profit
organizations that provide interdisciplinary team-based
primary health care; they are staffed by providers such as nurse
practitioners, nurses, social workers and dieticians. Physician
groups that can affiliate with and participate in FHTS are
funded by one of three compensation options: Blended
Capitation (such as FHN or FHO), Complement Based
Models (RNPGA or other specialized agreements) and BSM
(for community sponsored FHTs). FHTs are located across
Ontario, in both urban and rural settings, ranging in size,
structure, scope and governance.
MOHLTC negotiates many elements of physician compensation with the Ontario Medical Association (OMA).
The last Physician Services Agreement (PSA) expired on
March 31, 2014 and the MOHLTC and the OMA commenced
negotiations for a new PSA in January 2014. The MOHLTC
and the OMA negotiated from January 2014 to January 2015,
but they were unsuccessful in reaching a PSA. In the absence
of a new PSA, the MOHLTC implemented a set of initiatives
(Ten-Point Plan for Saving and Improving Service) to change
the funding for certain physician services and programs.
The MOHLTC continues to work with the OMA in hopes
that a new PSA can be agreed upon.
5.3 Payments to Hospitals
Ontario hospitals are funded through a mix of base funding,
which is on-going funding, and one-time funding. The majority
of funding provided to hospitals is through base funding, which
is comprised of several buckets of funding, including:
■■ Health System Funding Reform (HSFR);
■■ Global;
■■ Post-Construction Operating Plan (PCOP);
■■ Wait Times; and
■■ Priority Programs
On April 1, 2012, Ontario began the implementation of
the Health System Funding Reform (HSFR) Strategy for
funding hospitals. HSFR shifts health care funding from
a predominantly global budget system towards an activitybased funding model which ensures that patients get the right
care, at the right place, at the right time and at the right price.
HSFR offers an integrated approach to health system funding
and puts the patient at the core through adopting a ‘money
follows the patient’ principle. HSFR is a significant shift from
the way Ontario hospitals were traditionally funded, which
was largely based on historically-derived global budgets which
were established in 1969.
CHAPTER 3: ONTARIO
HSFR is comprised of two key components: Health Based
Allocation Model (HBAM) and Quality-Based Procedures
(QBP) funding, which together will comprise 50 percent of
hospital’s total funding in 2015–2016 (38 percent HBAM;
12 percent QBP).
Health-Based Allocation Model: Is an evidence-based,
health-based funding formula. HBAM enables the government
to equitably allocate available funding at the organizational
level to health service providers. HBAM uses an algorithm to
identify a health service provider’s future expense levels. A set
funding pot is then divided amongst providers based on this
future expense calculation and available funding. A health
system provider’s future expense is determined based on past
patient services delivered and efficiency, as well as population
and health information, such as: age, gender, population
growth rates, diagnosis and procedures. Each of the hospitals
funded under HBAM receive a share of a fixed pot of funding.
Quality-Based Procedures: QBPs are an integral part of
HSFR as they align funding with quality improvement. They
target clusters of patients with clinically related diagnoses or
treatments that have been identified by an evidence-based
framework as providing opportunity for process improvements,
clinical redesign improved patient outcomes, enhanced patient
experience and potential cost savings. QBPs allow the health
system to achieve better quality and system efficiencies through
utilizing a ‘price x volume x quality’ approach. The price for
each patient group is currently based on the average price of
providing care, adjusted for patient acuity.
Global budgets (non-HSFR) will continue to be used for
activities that cannot be modeled, including those are that
are unique (such as forensic mental health), or where HSFR
would introduce significant funding instability (such as
small hospitals).
Additional buckets of funding are hospital-specific. The
Post-Construction Operating Plan (PCOP) Program
provides operational funding to support the service and
facility expansions associated with approved capital projects.
Ontario’s Wait Time Strategy provides targeted funding to
improve access to key health services by reducing wait times.
Provincial Program funding supports programs such as
certain specialized cardiac services, that are managed at a
provincial rather than regional level.
Hospital Service Accountability Agreements (H-SAA):
When the Local Health Integration Networks (LHINs)
assumed responsibility for their local health care systems they
negotiated two year H-SAAs with their respective hospitals
and became the lead for the Hospital Annual Planning
Submissions, which are the precursors to the H-SAAs. The
LHINs have amended the 2008/09–2009/10 H-SAA each year
from 2010/11 to 2014/15 versus negotiating a new two year
agreement. These are referred to as Amending Agreements.
Public hospitals submit planning submissions to the
LHINs that are the result of broad consultations within the
organizations (all levels of staff, unions, physicians and board),
the community and region. Some of the data submitted in the
planning submissions are used to populate schedules for service
volumes and performance targets that form the contractual
basis for the H-SAA.
The H-SAA outlines the terms and conditions of the services
provided by the hospital, the funding it will receive, along with
the performance and service levels expected. There are various
performance indicators that are monitored, managed and
evaluated in the agreement.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
The Government of Ontario publicly acknowledged the federal
contributions provided through the Canada Health Transfer in
its Public Accounts of Ontario 2014–2015.
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CHAPTER 3: ONTARIO
REGISTERED PERSONS
2010–2011
1. Number as of March 31st (#).
13,100,000
2011–2012
13,212,728
1
2012–2013
1
13,349,791
2013–2014
1
13,452,921
2014–2015
13,545,565
1
1
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2010–2011
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
2011–2012
2012–2013
2013–2014
2014–2015
149
2
147
2
146
2
145
2
145
2
15,527,899,500
3
16,173,889,100
3
16,418,200,000
3
16,361,203,000
3
16,377,339,000
3
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4. Number of private for-profit facilities
providing insured health services (#).
not available
4
not available
4
not available
4
not available
4
not available
4
5. Payments to private for-profit facilities
for insured health services ($).
not available
4
not available
4
not available
4
not available
4
not available
4
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
8,231
6,365
7,019
6,924
7,087
68,384,505
46,960,837
58,107,802
60,733,276
65,048,142
130,855
116,541
130,058
133,429
136,778
35,431,819
33,598,383
37,866,652
41,057,654
42,332,365
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA 5
10.Total number of claims, in-patient (#).
28,420
30,348
29,616
26,354
33,296
52,706,316
42,559,353
43,824,878
45,624,997
54,634,942
12.Total number of claims, out-patient (#).
not available
not available
not available
not available
not available
13.Total payments, out-patient ($).
not available
not available
not available
not available
not available
11. Total payments, in-patient ($).
1. These estimates represent the number of Valid and Active Health Cards (have current eligibility and resident has incurred a claim in the last 7 years).
2. Number represents all publicly funded hospitals excluding specialty psychiatric hospitals. Specialty psychiatric hospitals are excluded in order to conform
to Canada Health Act Annual Report requirements.
3. Amount represents funding for all public hospitals excluding specialty psychiatric hospitals. Fiscal Year 2014–2015 is based on Public Accounts.
4. Data are not collected in a single system in MOHLTC. Further, the MOHLTC is unable to categorize providers/facilities as “for-profit” as MOHLTC does not
have financial statements detailing service providers’ disbursement of revenues from the Ministry.
5. Indicators 10 and 11 include both in-patient and out-patient.
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CHAPTER 3: ONTARIO
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of not participating physicians (#). 6
17. Total payments for services provided
by physicians paid through all payment
methods ($).7
18.Total payments for services provided by
physicians paid through fee-for-service ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
25,995
26,818
27,242
28,488
29,380
34
32
29
28
24
0
0
0
0
0
10,374,311,208
11,008,532,900
11,228,719,988
11,379,311,227
11,823,825,604
7,052,261,365
7,508,636,523
7,402,377,170
7,600,334,259
7,784,933,027
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
723,766
536,447
553,823
672,661
623,076
25,237,480
25,252,852
26,017,930
30,248,528
31,360,835
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
213,717
234,420
214,080
192,773
170,362
12,455,597
7,922,281
6,537,845
5,844,999
6,473,814
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
282
262
273
275
275
96,797
96,735
93,672
95,810
96,258
13,525,890
13,532,519
12,525,404
12,713,974
12,040,331
6. Ontario has no non-participating physicians, only opted-out physicians who are reported under item #15.
7. Total payments includes payments made to Ontario physicians through Fee-for-Service, Primary Care, Alternate Payment Programs, Academic Health
Science Centres, the Hospital On Call Program and Health Care Connect. Services and payments related to Other Practitioner Programs, Out-of-Country/
Out-of-Province Programs, Nurse Practitioners, Interprofessional Shared Care, NP Led Clinics, Family Health Teams and Community Labs are excluded.
Fiscal Years 2010–2011, 2011–2012, 2012–2013, 2013–2014, and 2014–2015 agree with Public Accounts.
CANADA HEALTH ACT
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MANITOBA
INTRODUCTION
Manitoba Health, Healthy Living and Seniors (MHHLS)
provides leadership and support to protect, promote and
preserve the health of all Manitobans. MHHLS continues
efforts to improve access, service delivery, capacity, innovation,
sustainability and improve the health status of Manitobans
while reducing health disparities. The roles and responsibilities
of the department include policy, program and standards
development; fiscal and program accountability; and evaluation.
In addition, specific direct services continue to be provided
through Selkirk Mental Health Centre, Cadham Provincial
Laboratory, public health inspections, and provincial
nursing stations.
MHHLS remains committed to the principles of Medicare and
improving the health status of all Manitobans. In 2014–2015
Manitoba continued to support these commitments through the
following activities:
■■ Negotiated agreements with Doctors Manitoba, Manitoba
Nurses Union (MNU), and other health professional
associations. The Doctors Manitoba and MNU agreements
include provisions for collaboration on health system
improvements and efficiencies.
■■ Increased the overall number of specialist physicians,
general practitioners, registered nurses, nurse practitioners,
registered psychiatric nurses, and licensed practical nurses.
■■ Partnered with Manitoba Blue Cross to launch a modernized
medical claims processing system.
■■ Expanded, streamlined and increased efficiencies of the
Electronic Medical Record (EMR) Repository, with
over 130 (and growing) primary care clinics regularly
submitting EMR data.
■■ Continued to collaborate with the Winnipeg Regional
Health Authority and CancerCare Manitoba on the
implementation of the cancer treatment access strategy
entitled, “Transforming the Cancer Patient Journey in
Manitoba,” which aims to reduce the time from suspicion
to treatment to two months or less.
■■ Improved access and quality of primary health care,
including development of Quick Care clinics, primary care
mobile clinics, the Advanced Access program, My Health
Teams and further enhancements to the Family Doctor
Finder program.
■■ Released “Advancing Continuing Care — A Blueprint
to Support System Change,” which outlines priority
actions in continuing care to meet the needs of individuals
and families.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
The Manitoba Health Services Insurance Plan (MHSIP)
is administered by Manitoba Health, Healthy Living and
Seniors (MHHLS) under the Health Services Insurance Act,
R.S.M. 1987, c. H35.
The MHSIP is administered under this Act and insures
the costs of hospital, personal care, and medical and other
health services referred to in acts of the Legislature or
related regulations.
The Minister of Health is responsible for administering and
operating the MHSIP. The Minister may also enter into
contracts and agreements with any person or group that he
or she considers necessary for the purposes of the Act.
The Minister may also make grants to any person or group
for the purposes of the Act on such terms and conditions that
are considered advisable. Also, the Minister may, in writing,
delegate to any person any power, authority, duty or function
conferred or imposed upon the Minister under the Act or under
the regulations.
There were no legislative amendments to the Act or the
regulations in the 2014–2015 fiscal year that affected the
public administration of the MHSIP.
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CHAPTER 3: MANITOBA
1.2 Reporting Relationship
Section 6 of the Health Services Insurance Act requires the
Minister to have audited financial statements of the MHSIP
showing separately the expenditures for hospital services,
medical services and other health services. The Minister is
required to prepare an annual report, which must include the
audited financial statements, and to table the report before
the Legislative Assembly within 15 days of receiving it,
if the Assembly is in session. If the Assembly is not in session,
the report must be tabled within 15 days of the beginning of
the next session.
1.3 Audit of Accounts
Section 7 of the Health Services Insurance Act requires that
the Office of the Auditor General of Manitoba (or another
auditor designated by the Office of the Auditor General of
Manitoba) audit the accounts of the MHSIP annually and
prepare a report on that audit for the Minister. The most
recent audit reported to the Minister and available to the
public is for the 2014–2015 fiscal year and is contained in the
Manitoba Health Annual Report, 2014–2015. It is available
at www.gov.mb.ca/health/ann/index.html.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
Sections 46 and 47 of the Health Services Insurance Act, as
well as the Hospital Services Insurance and Administration
Regulation (M.R. 48/93), provide for insured hospital services.
As of March 31, 2015, there were 96 facilities providing
insured hospital services to both in-patients and out-patients.
Hospitals are designated by the Hospitals Designation
Regulation (M.R. 47/93) under the Act.
Services specified by the Regulation as insured in-patient
and out-patient hospital services include: accommodation and
meals at the standard ward level; necessary nursing services;
laboratory, radiological and other diagnostic procedures; drugs,
biologics and related preparations; routine medical and surgical
supplies; use of operating room, case room and anaesthetic
facilities; and use of radiotherapy, physiotherapy, occupational
and speech therapy facilities where available.
The Regulation states that hospital in-patient services include
routine medical and surgical supplies, thereby ensuring reasonable
access for all residents. The regional health authorities and
Manitoba Health, Healthy Living and Seniors (MHHLS)
monitor compliance.
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Manitoba residents maintain high expectations for quality health
care and insist that the best available medical knowledge and
service be applied to their personal health situations.
2.2 Insured Physician Services
The enabling legislation that provides for insured physician
services is the Medical Services Insurance Regulation
(M.R. 49/93) made under the Health Services Insurance Act.
Physicians providing insured services in Manitoba must be
lawfully entitled to practice medicine in Manitoba, and be
registered and licensed under the Medical Act.
The number of medical practitioners registered with MHHLS
to provide insured services as of March 31, 2015 was 2,510.
A physician, by giving notice to the Minister in writing,
may elect to collect the fees other than from the Minister for
medical services rendered to insured persons, in accordance
with section 91 of the Act and section 5 of the Medical
Services Insurance Regulation. The election to opt out of
the health insurance plan takes effect on the first day of the
month following a 90-day period from the date the Minister
receives the notice.
Before rendering a medical service to an insured person,
physicians must give the patient reasonable notice that they
propose to collect any fee for the medical service from them
or any other person except the Minister. The physician is
responsible for submitting a claim to the Minister on the
patient’s behalf and cannot collect fees in excess of the
benefits payable for the service under the Act or Regulations.
No physicians opted out of the medical plan in 2014–2015.
The range of physician services insured by MHHLS is listed
in the Payment for Insured Medical Services Regulation
(M.R. 95/96). Coverage is provided for all medically required
personal health care services that are not excluded under
the Excluded Services Regulation (M.R. 46/93) of the Act,
rendered to an insured person by a physician.
During fiscal year 2014–2015, a number of new insured services
were added to a revised fee schedule. The Physician’s Manual,
including all insured medical services, can be viewed on-line at:
www.gov.mb.ca/health/manual/index.html.
The process for a medical service to be added to the list of
those covered by MHHLS is that physicians must put forward
a proposal to their specific section of Doctors Manitoba.
Doctors Manitoba will negotiate the item, including the fee,
with MHHLS. MHHLS may also initiate this process.
CHAPTER 3: MANITOBA
2.3 Insured Surgical-Dental Services
Insured surgical and dental services are listed in the
Hospital Services Insurance and Administration Regulation
(M.R. 48/93) under the Health Services Insurance Act. Surgical
services are insured when performed by a certified oral and
maxillofacial surgeon or a licensed dentist in a hospital, when
hospitalization is required for the proper performance of the
procedure. This Regulation also provides benefits relating to
the cost of insured orthodontic services in cases of cleft lip
and/or palate for persons registered under the program by their
18th birthday, when provided by a registered orthodontist.
Providers of dental services may elect to collect their fees
directly from the patient in the same manner as physicians
and may not charge to, or collect from, an insured person a fee
in excess of the benefits payable under the Act or regulations.
No providers of dental services had opted out in 2014–2015.
In order for a dental service to be added to the list of insured
services, a dentist must put forward a proposal to the Manitoba
Dental Association (MDA). The MDA negotiates the item and
fee with MHHLS.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
The Excluded Services Regulation (M.R. 46/93) made under
the Health Services Insurance Act sets out those services that are
not insured. These include: examinations and reports for reasons
of employment, insurance, attendance at university or camp, or
performed at the request of third parties; group immunization
or other group services except where authorized by MHHLS;
services provided by a physician, dentist, chiropractor or
optometrist to him or herself or any dependants; preparation
of records, reports, certificates, communications and testimony
in court; mileage or travelling time; services provided by
psychologists, chiropodists and other practitioners not provided
for in the legislation; in vitro fertilization; tattoo removal;
contact lens fitting; reversal of sterilization procedures; and
psychoanalysis.
All Manitoba residents have equitable access to services. Third
parties such as private insurers or the Workers Compensation
Board do not receive priority access to services through
additional payment. Manitoba has no formalized process
to monitor compliance; however, feedback from physicians,
hospital administrators, medical professionals and staff allows
regional health authorities and MHHLS to monitor usage and
service concerns.
To de-insure services covered by MHHLS, the Ministry
prepares a submission for approval by Cabinet. The need
for public consultation is determined on an individual basis
depending on the subject.
No services were removed from the list of those insured by
MHHLS in 2014–2015.
3.0UNIVERSALITY
3.1Eligibility
The Health Services Insurance Act defines the eligibility of
Manitoba residents for coverage under the provincial health
care insurance plan.
Section 2(1) of the Act states that a resident is a person who
is legally entitled to be in Canada, makes his or her home
in Manitoba, is physically present in Manitoba for at least
six months in a calendar year, and includes any other person
classified as a resident in the regulations, but does not include
a person who holds a temporary resident permit under the
Immigration and Refugee Protection Act (Canada), unless
the Minister determines otherwise, or is a visitor, transient
or tourist.
The Residency and Registration Regulation (M.R. 54/93)
extends the definition of residency. The extensions are found
in sections 7(1) and 8(1). Section 7(1) allows missionaries,
individuals with out-of-country employment and individuals
undertaking sabbatical leave to be outside Manitoba for up
to two years while still remaining residents of Manitoba.
Students are deemed to be Manitoba residents while in full-time
attendance at an accredited educational institution. Section 8(1)
extends residency to individuals who are legally entitled to work
in Manitoba and have a work permit of 12 months or more and
to individuals who hold study permits of six months or more
under the Immigration and Refugee Protection Act (Canada).
Additionally, section 8.1.1 of the Residency and Registration
Regulation extends deemed residency to temporary foreign
workers (and their dependants) in the province to provide
agricultural services on the basis of a work permit, regardless
of the duration of their work permit.
The Residency and Registration Regulation, section 6, defines
Manitoba’s waiting period as follows:
“A resident who was a resident of another Canadian
province or territory immediately before his or her arrival
in Manitoba is not entitled to benefits until the first day
of the third month following the month of arrival.”
Section 6 of the Residency and Registration Regulation
stipulates that there is no waiting period for dependants
of members of the Canadian Armed Forces.
There are currently no other waiting periods in Manitoba.
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CHAPTER 3: MANITOBA
The Manitoba Health Services Insurance Plan (MHSIP)
excludes residents covered under any federal plan, including the
following federal statutes: Aeronautics Act; Civilian War-related
Benefits Act; Government Employees Compensation Act; Merchant
Seaman Compensation Act; National Defence Act; Pension Act;
Veteran’s Rehabilitation Act; federal inmates or those covered
under legislation of any other jurisdiction (Excluded Services
Regulations subsection 2(2)). These residents become eligible
for health services insurance coverage upon discharge from the
Canadian Forces, or in the case of an inmate of a penitentiary,
upon discharge if the inmate has no resident dependants. Upon
change of status, these persons have one month to register with
Manitoba Health, Healthy Living and Seniors (MHHLS)
(Residency and Registration Regulation (M.R. 54/93,
subsection 2(3)).
RCMP members are insured persons in Manitoba and are
eligible for benefits under the MHSIP.
The process of issuing health insurance cards requires that
individuals inform and provide documentation to MHHLS
that they are legally entitled to be in Canada, and that they
intend to be physically present in Manitoba for six months in
a calendar year. They must also provide a primary residence
address in Manitoba. Upon receiving this information,
MHHLS will provide a registration card for the individual
and all qualifying dependants.
Manitoba has two health-related numbers. The registration
number is a six-digit number assigned to an individual 18 years
of age or older who is not classified as a dependant. This number
is used by MHHLS to pay for all medical service claims for that
individual and all designated dependants. A nine-digit Personal
Health Identification Number (PHIN) is used for payment of
all hospital services and for the provincial drug program.
As of March 31, 2015, there were 1,317,861 residents registered
with the MHSIP.
There is no provision for a resident to opt out of the MHSIP.
3.2 Other Categories of Individuals
The Residency and Registration Regulation (M.R. 54/93,
sub-section 8(1)) requires that temporary workers possess a
work permit issued by Citizenship and Immigration Canada
for at least 12 consecutive months, be physically present in
Manitoba for six months in a calendar year, and be legally
entitled to be in Canada before receiving MHSIP coverage.
Section 8.1(a.1) of the Residency and Registration Regulation
extends deemed residency to foreign students (and their
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CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
dependants) holding a valid study permit with a duration
of 12 months or more.
Section 8.1.1 of the Residency and Registration Regulation
extends deemed residency to temporary foreign workers
(and their dependants) in the province to provide agricultural
services on the basis of a work permit, regardless of the
duration of their work permit.
4.0PORTABILITY
4.1 Minimum Waiting Period
The Residency and Registration Regulation (M.R. 54/93,
section 6) identifies the waiting period for insured persons from
another province or territory. A resident who lived in another
Canadian province or territory immediately before arriving
in Manitoba is entitled to benefits on the first day of the
third month following the month of arrival.
4.2 Coverage During Temporary Absences
in Canada
The Residency and Registration Regulation (M.R. 54/93
section 7(1)) defines the rules for portability of health
insurance during temporary absences in Canada.
Students are considered residents and will continue to
receive health coverage for the duration of their full-time
enrolment at any accredited educational institution. The
additional requirement is that they intend to return and
reside in Manitoba after completing their studies. Manitoba
has formal agreements with all Canadian provinces and
territories for the reciprocal billing of insured hospital services.
In-patient costs are paid at standard rates approved by the
host province or territory. Payments for in-patient, high-cost
procedures and out-patient services are based on national rates
agreed to by provincial and territorial health plans. These
include all medically necessary services as well as costs for
emergency care.
Except for Quebec, medical physician services incurred in all
provinces or territories are paid through a reciprocal billing
agreement at host province or territory rates. Claims for
physician medical services received in Quebec are submitted
by the patient or physician to Manitoba Health, Healthy Living
and Seniors (MHHLS) for payment at host province rates.
CHAPTER 3: MANITOBA
4.3 Coverage During Temporary Absences
Outside Canada
5.0ACCESSIBILITY
The Residency and Registration Regulation (M.R. 54/93, subsection 7(1)) defines the rules for portability of health insurance
during temporary absences from Canada.
5.1 Access to Insured Health Services
Section 7(1)(g) of the Residency and Registration Regulation
extends the period during which a person may be temporarily
absent from Manitoba for the purpose of residing outside of
Canada from six months to a maximum of seven months in
a 12-month period.
Residents on full-time employment contracts outside Canada
will receive health services insurance coverage for up to
24 consecutive months. Individuals must return and reside in
Manitoba after completing their employment terms. Clergy
serving as humanitarian aid workers or missionaries on behalf
of a religious organization approved as a registered charity
under the Income Tax Act (Canada) will be covered by MHHLS
for up to 24 consecutive months. Students are considered
residents and will continue to receive health coverage for
the duration of their full-time enrollment at an accredited
educational institution. The additional requirement is that
they intend to return and reside in Manitoba after completing
their studies. Residents on sabbatical or educational leave
from employment will be covered by MHHLS for up to
24 consecutive months. These individuals also must return
and reside in Manitoba after completing their leave.
Manitobans requiring medically necessary hospital services
unavailable in Manitoba or elsewhere in Canada may be eligible
for costs incurred in the United States by providing MHHLS
with a recommendation from a specialist stating that the
patient requires a specific, medically necessary service.
4.4 Prior Approval Requirement
Prior approval is not required for procedures that are covered
under the interprovincial reciprocal agreements with other
provinces. Prior approval by MHHLS is required for high
cost items or procedures that are not included in the reciprocal
agreements.
All non-emergency hospital and medical care provided outside
Canada requires prior approval from MHHLS.
Manitoba Health, Healthy Living and Seniors (MHHLS)
ensures that medical services are equitable and reasonably
available to all Manitobans. Effective January 1, 1999,
the Surgical Facilities Regulation (M.R. 222/98) under
the Health Services Insurance Act came into force to prevent
private surgical facilities from charging additional fees for
insured medical services.
The Health Services Insurance Act, the Private Hospitals Act and
the Hospitals Act include definitions and other provisions
to ensure:
■■ that no charges can be made to individuals who receive
insured surgical services, or to anyone else on that person’s
behalf; and
■■ that a surgical facility cannot perform procedures requiring
overnight stays and thereby function as a private hospital.
MHHLS continues to invest in improving clients’ access. To
achieve Manitoba’s commitment that all Manitobans who wish
to will have access to a family physician, investments continue
to be made in initiatives such as Primary Care Networks
and inter-professional teams. In addition, Manitoba opened
a fifth Quick Care Clinic; operated two mobile clinics, one
in the Prairie-Mountain Regional Health Authority (RHA)
and the other in the Southern Health-Santé Sud RHA; and
introduced more opportunities and supports for Manitobans
to self-manage their health care. Investment also continued in
existing initiatives that enhance capacity, quality and efficiency
in primary care, such as the Physician Integrated Network,
TeleCARE Manitoba (a chronic disease self-management
resource for congestive heart failure and diabetes), and an
After-Hours Call Community Network (a network of general
practitioners linked to patients through the 24-hour Health
Links-Info Santé service).
Since 2008, MHHLS funded and coordinated over 90 primary
clinics, regional community programs and specialty clinics
to successfully complete the Advanced Access training,
enabling them to offer patients same-day access to a primary
care provider and five-day access to a specialist or community
program. Since 2013, the redeveloped Family Doctor Finder
program has enabled Manitobans to call or e-mail to be
registered and connected with a primary care provider. This
includes Regional Primary Care Connectors, who work
with regional primary care providers to find capacity in their
practices to see new patients. To date, over 28,000 Manitobans
without a provider have found one through the program.
CANADA HEALTH ACT
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CHAPTER 3: MANITOBA
The Cancer Patient Journey initiative was established in 2011
to streamline cancer services and dramatically reduce the wait
time for patients between the time cancer is suspected and the
start of effective treatment to two months or less. Key initiative
activities to date include:
■■ Facilitating the work of the Rapid Improvement Leads
with stakeholders to identify process efficiencies and
improvements related to diagnosis and treatment.
■■ Opening of the Regional Cancer Program Hubs located in
Thompson, The Pas, Steinbach and Winnipeg. These Cancer
Hubs are oncology out-patient units focused on delivering
chemotherapy as well as providing navigation services,
psychosocial support and enhanced access to clinical
expertise. They serve to expedite cancer diagnosis and
treatment for people inside and outside Winnipeg.
■■ Clinical pathways for breast and colorectal cancer for
suspicion of cancer to treatment were completed with
broad consultation and validation among clinicians.
■■ Patient trackers were hired to track a patient’s journey
from suspicion of cancer to diagnosis.
In November 2012 the province released an updated framework
“Manitoba’s Cancer Strategy 2012–2017” for cancer control
that will guide actions to build on the major successes delivered
under the 2007 provincial cancer strategic framework. The
document, created with input from partners, stakeholders
and cancer patients themselves, outlines an integrated and
cohesive approach to cancer that involves prevention, screening,
diagnosis, research, treatment, palliative care and survivorship.
Key activities to date include:
■■ Expanding the hours of the Urgent Care Clinic and Helpline
at CancerCare Manitoba (CCMB) to provide after-hours
support to Manitobans facing cancer. The Urgent Care Clinic
assists patients with cancer-related complications and sideeffects from treatment, such as dehydration, pain, nausea,
digestive issues, and fatigue. The helpline is a dedicated phone
line answered by registered nurses with oncology training,
to provide support and advice to cancer patients faced with
urgent issues and direct them to appropriate services.
■■ The implementation of the provincial conversion of Film
Screen Mammography equipment to Digital Mammography.
■■ Implementing liquid based cytology as a platform for future
HPV testing in Manitoba.
■■ The development of cancer prevention concepts
including smoking cessation, genetic testing and
radiation exposure legislation.
■■ Grant funding to assist in the service delivery of the Canadian
Cancer Society transportation program to ensure patients
receive transportation to cancer treatment and appointments
no matter where they live in the province.
■■ The Research Institute of Oncology and Hematology at
CancerCare Manitoba consolidated all cancer researchers
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under one umbrella institute which has resulted in cross
talk, efficiency and awareness of all cancer research while
also including the patient experience and prevention.
■■ Increasing the number of medical oncologists with
a special interest in gastro intestinal malignancies
(including pancreatic cancers).
Other improvements in Cancer and Diagnostic care include:
■■ Plans to expand and renovate the Thompson Hospital’s
chemotherapy space providing a larger, more functional
environment for patients and staff alike.
■■ The preliminary design of a new CancerCare Building.
■■ Additional renal dialysis capacity was added through
funding for an additional four stations to provide service
to 24 patients in Winnipeg.
■■ Additional MRI capacity was added through expansion
of service hours.
■■ Expansion of after hours and emergency diagnostic testing
for computed tomography in rural Manitoba.
■■ Provincial Lab Information System (PLIS) implementation
at 13 additional sites within Manitoba. The PLIS enables
electronic delivery of rural lab results to clinical data
repositories, emergency departments and to electronic
medical records.
■■ Replacement of Computed Radiography facilities at
Ste. Anne, Minnedosa, Neepawa, Glenboro and Souris.
This new equipment provides digital images that are
sent to radiologists electronically resulting in improved
turnaround times so that patients receive their test results
faster and improved access for physicians to enhance
treatment planning.
A three million dollar cross-departmental grant aimed at
improving the health and quality of life for Manitobans
living with spinal cord injury and related disabilities has
been established.
Manitoba continues to experience growth in the number of
active practicing nurses. There were 17,806 active practicing
nurses in Manitoba in 2014. This represents a net gain of
11 nurses over 2013 (17,795).
A renewed Collective Agreement was reached with the
Manitoba Nurses’ Union (MNU) on April 9, 2014 and is in
effect for four years, from April 1, 2013 to March 31, 2017.
The Agreement provides for wage increases of 10.1% over
four years, which breaks down as follows: 2% retroactively
for 2013; 2% in 2014 plus 1.1% market adjustment; 2% in 2015;
and 2% in 2016 plus a 1% market adjustment. As part of the
new Agreement, the parties made a number of post-bargaining
commitments, including the commitment to identify, develop
and implement system delivery changes intended to improve
the effectiveness and efficiency of health care service delivery
in Manitoba.
CHAPTER 3: MANITOBA
The Nurses Recruitment and Retention Fund, established in
1999, continues to contribute to the nursing supply in terms of
both recruitment and retention in Manitoba. Financial support
has continued to be provided in order to assist nurses of all
categories to offset the cost of relocating to work in Manitoba,
as well as offering funding to encourage nurses to work in
rural and northern regions and other areas of need in order
to enhance the delivery of health care across the province.
In addition to continued implementation of the overall healthcare
transformation whereby more services may be provided in the
community, in primary care settings, efforts will be undertaken
over the next few years to plan for addressing both the increasing
age of this workforce, in terms of retirements, as well as the
advancing age of the population in terms of the need for long
term care services.
The Province has been supporting the expansion of the
Physician Assistant (PA) role in Manitoba. PAs are highly
skilled health care professionals who practice medicine under
the supervision of licensed physicians. PAs are regulated by
the College of Physicians & Surgeons of Manitoba (CPSM)
and must be registered with the CPSM in order to practice
in Manitoba. The CPSM determines a PA’s specific scope
of practice by approving their practice description, which is
signed by their supervising physician.
Since Manitoba established its PA Regulation in 1999 the role
of the PA has grown from positions with acute surgical units
(general, orthopedic and cardiac) to having PAs providing
clinical support in areas of mental health, internal medicine,
oncology and primary care. PAs working in primary care in
Manitoba have ranged from ‘solo’ practices in rural Manitoba,
supervised and supported by physicians in a nearby community,
to working in both regional health authority run primary
care clinics and community-based fee-for-service clinics. The
demand for PAs continues to grow as the profession has shown
great adaptability to address access and service challenges
throughout Manitoba’s health system. As of March 2015,
there were 65 PAs registered with the CPSM.
5.2 Physician Compensation
Manitoba continues to employ the following methods of
payment for physicians: fee-for-service, contract, blended and
sessional. The Health Services Insurance Act governs remuneration
to physicians for insured services. There were no amendments
to the Health Services Insurance Act related to physician
compensation during the 2014–2015 fiscal year.
Fee-for-service remains the primary method of payment for
physician services. Alternate payment arrangements constitute
a significant portion of the total compensation to physicians
in Manitoba. Alternate-funded physicians are those who
receive non fee-for-service compensation, including through
a salary (employment relationship) or those who work on
an independent contract basis. Manitoba also uses blended
payment methods where appropriate. As well, physicians may
receive sessional payments for providing medical services on
a time based arrangement, as well as stipends for on-call and
other responsibilities.
Manitoba Health, Healthy Living and Seniors represents
Manitoba in negotiations with physicians. The physicians are
typically represented by Doctors Manitoba with some exceptions,
such as oncologists engaged by CancerCare Manitoba.
Negotiations to renew the Master Agreement between Doctors
Manitoba and Manitoba, which expired on March 31, 2015,
took place during the 2014–2015 fiscal year.
The Manitoba Physician’s Manual lists all of the fee tariff
descriptions, rates, rules of application and the dispute resolution
process in relation to fee-for-service payments to physicians. This
document is the Schedule of Benefits payable to physicians on behalf
of insured persons in Manitoba pursuant to the Medical Services
Insurance Regulation under The Health Services Insurance Act.
All fee-for-service claims must be submitted electronically. The
submission of paper claims is permitted on a limited basis and only
with the prior approval of Manitoba Health. Fee-for-service claims
must be received within six months of the date upon which the
physician rendered the service.
During the 2014–2015 fiscal year, final preparations were made for
implementation of a new claims processing system to replace the
legacy system which has been in use for over 40 years.
5.3 Payments to Hospitals
Division 3.1 of Part 4 of the Regional Health Authorities Act sets
out the requirements for operating agreements between regional
health authorities and the operators of hospitals and personal
care homes, defined as “health corporations” under the Act.
Pursuant to the provisions of division 3.1, regional health
authorities are prohibited from providing funding to a health
corporation for operational purposes unless the parties have
entered into a written agreement for this purpose that: enables
the health services to be provided by the health corporation;
enables the funding to be provided by the regional health
authority for the health services; sets out the terms of the
agreement; and includes a dispute resolution process and
remedies for breaches. If the parties cannot reach an agreement,
the Act enables them to request that the Minister of Health
appoint a mediator to help them resolve outstanding issues.
If the mediation is unsuccessful, the Minister is empowered
to resolve the matter or matters in dispute. The Minister’s
resolution is binding on the parties.
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CHAPTER 3: MANITOBA
There are three regional health authorities which have hospitals
operated by health corporations in their health regions. The
regional health authorities have required agreements with
health corporations that enable the regional health authority
to determine funding based on objective evidence, best
practices and criteria that are commonly applied to comparable
facilities. In all other regions, the hospitals are operated by the
Regional Health Authorities Act. Section 23 of the Act requires
that regional health authorities allocate their resources in
accordance with the approved regional health plan.
The allocation of resources by regional health authorities for
providing hospital services is approved by MHHLS through
the approval of regional health plans, which the regional health
authorities are required to submit for approval pursuant to
section 24 of the Regional Health Authorities Act. Section 23
of the Act requires that authorities allocate their resources
in accordance with the approved regional health plan.
Pursuant to subsection 50(2.1) of the Health Services Insurance
Act, payments from the Manitoba Health Services Insurance
Plan (MHSIP) for insured hospital services are to be paid to
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CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
the regional health authorities. In relation to those hospitals
that are not owned and operated by a regional health authority,
the regional health authority is required to pay each hospital in
accordance with any agreement reached between the regional
health authority and the hospital operator.
No legislative amendments to the Act or the regulations
in 2014–2015 had an effect on payments to hospitals.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
Manitoba regularly recognizes the federal role regarding
the contributions provided under the Canada Health
Transfer (CHT) in public documents. Federal transfers are
identified in the Estimates of Expenditures and Revenue
(Manitoba Budget) document and in the Public Accounts
of Manitoba. Both documents are published annually by
the Manitoba government.
CHAPTER 3: MANITOBA
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1,230,270
1,265,059
1,271,388
1,289,268
1,317,861
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#).
5. Payments to private for-profit facilities
for insured health services ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
96
96
96
96
96
not available
not available
not available
not available
not available
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1
1
1
1
1
1,541,540
2,005,150
1,928,985
2,040,914
not available
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
2,844
2,899
2,690
2,978
2,829
27,092,558
26,478,561
25,548,935
29,138,109
25,458,440
30,983
29,070
31,270
33,999
32,083
10,454,203
10,706,338
10,073,238
11,830,872
11,010,715
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
634
646
628
722
614
2,454,364
1,913,457
4,317,523
1,826,483
1,697,912
10,706
11,311
11,408
12,145
12,028
3,022,630
3,226,581
3,193,548
3,080,536
3,344,999
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CHAPTER 3: MANITOBA
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
2,276
2,322
2,354
2,354
2,510
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
17. Total payments for services provided
by physicians paid through all payment
methods ($).
920,890,000
927,916,000 988,164,000
1,082,193,000
1,134,521,000
18.Total payments for services provided by
physicians paid through fee-for-service ($).
553,924,806
595,083,828
593,129,217
659,208,383
742,136,000
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of not participating physicians (#).
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
267,122
231,683
238,400
226,473
244,903
9,909,927
10,989,977
11,127,080
11,137,758
11,963,709
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
7,226
8,285
7,984
8,216
7,785
953,272
703,353
1,148,432
888,084
1,048,275
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
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CANADA HEALTH ACT
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
133
131
160
166
190
5,475
5,290
5,236
5,656
6,397
1,522,545
1,468,524
1,231,972
1,493,071
2,083,453
ANNUAL REPORT 2014–2015
SASKATCHEWAN
INTRODUCTION
Saskatchewan’s Ministry of Health strives to put patients
first by building a responsive, integrated, and efficient health
system that enables people to achieve their best possible health.
The Ministry is exploring innovative approaches based on
targets in four areas: better health, better care, better value,
and better teams. The needs and values of patients and
families are reflected in both planning and delivery of care,
through a system-wide focus on quality improvement (Lean)
management processes.
Saskatchewan’s health care system includes 12 regional health
authorities, the Saskatchewan Cancer Agency, eHealth
Saskatchewan, 3sHealth (Shared Services Saskatchewan),
the Athabasca Health Authority, affiliated health care
organizations, and a diverse group of professionals, many
of whom are in private practice. There are 26 self-regulated
health professions in the province and the health system as a
whole employs more than 40,000 people who provide a broad
range of services. The Ministry provides governance training
and effective strategic oversight to the Boards of Directors
of regional health authorities and the Saskatchewan Cancer
Agency and encourages leadership from boards, management,
and health professionals at all levels.
The Ministry also supports the efforts of regional health
authorities, the Saskatchewan Cancer Agency, and other
stakeholders to recruit and retain health care providers,
including nurses and physicians. Partnerships with local,
regional, provincial, national and international organizations
are fundamental to providing all Saskatchewan residents with
access to quality health care services.
Visit www.saskatchewan.ca for more information about
Ministry programs and services.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
The provincial government is responsible for funding and
ensuring the provision of insured hospital, physician and
surgical-dental services in Saskatchewan. Section 6.1 of the
Health Administration Act authorizes that the Minister of
Health may:
■■ pay part of, or the whole of, the cost of providing health
services for any persons or classes of person who may be
designated by the Lieutenant Governor-in-Council;
■■ make grants or loans, or provide subsidies to regional health
authorities, health care organizations or municipalities
for providing and operating health services or public
health services;
■■ pay part of, or the whole of, the cost of providing health
services in any health region or part of a health region
in which those services are considered by the Minister
to be required;
■■ make grants or provide subsidies to any health agency that
the Minister considers necessary; and
■■ make grants or provide subsidies to stimulate and develop
public health research, and to conduct surveys and studies
in the area of public health.
Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act
provide the authority for the Minister of Health to establish
and administer a plan of medical care insurance for residents.
The Regional Health Services Act, implemented in 2002, provides
the authority to establish 12 regional health authorities.
Sections 3 and 9 of the Cancer Agency Act provide for
establishing a Saskatchewan Cancer Agency and for the
Agency to coordinate a program for diagnosing, preventing
and treating cancer.
The mandates of the Ministry of Health, regional health
authorities and the Saskatchewan Cancer Agency are outlined
in the Health Administration Act, the Regional Health Services Act
and the Cancer Agency Act.
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CHAPTER 3: SASKATCHEWAN
1.2 Reporting Relationship
The Ministry of Health is directly accountable, and regularly
reports, to the Minister of Health on the funding, and
administering the funds, for insured physician, surgical-dental
and hospital services.
Section 36 of the Saskatchewan Medical Care Insurance Act
requires that the Minister of Health submit an annual
report concerning the medical care insurance plan to the
Legislative Assembly.
The Regional Health Services Act requires that each regional
health authority shall submit to the Minister of Health:
■■ a report on the activities of the regional health authority; and
■■ a detailed, audited set of financial statements.
Pursuant to legislation, these reports and corresponding
statements are then provided by the Minister to the
Legislative Assembly.
Section 54 of the Regional Health Services Act requires that
regional health authorities and the Cancer Agency submit to
the Minister any reports that the Minister may request from
time to time. Regional health authorities and the Cancer
Agency are required to submit various financial documents and
a health service plan to the Saskatchewan Ministry of Health.
1.3 Audit of Accounts
The Provincial Auditor conducts an annual audit of government
ministries and agencies, including the Ministry of Health.
It includes an audit of Ministry payments including but not
limited to regional health authorities, the Saskatchewan Cancer
Agency, and physicians and dental surgeons for insured
physician and surgical-dental services.
Section 57 of the Regional Health Services Act requires that an
independent auditor, who possesses the prescribed qualification
and is appointed for that purpose by a regional health authority
and the Cancer Agency, audit the accounts of a regional health
authority or the Cancer Agency at least once in every fiscal year.
Each regional health authority and the Cancer Agency must
annually submit to the Minister of Health a detailed, audited
set of financial statements.
The most recent audits were for the year ending March 31, 2015.
The audits of the Government of Saskatchewan, regional health
authorities and Saskatchewan Cancer Agency are tabled in the
Saskatchewan Legislature each year. The reports are available
to the public directly from each entity and are available on
their websites.
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The Office of the Provincial Auditor for Saskatchewan also
prepares reports to the Legislative Assembly of Saskatchewan.
These reports are designed to assist the government in
managing public resources and to improve the information
provided to the Legislative Assembly. They are available on
the Provincial Auditor’s website at: http://www.auditor.sk.ca.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
Section 8 of the Regional Health Services Act gives the Minister
the authority to provide funding to a regional health authority
or a health care organization for the purpose of the Act.
Section 10 of the Act permits the Minister to designate
facilities including hospitals, special care homes and health
centres. Section 11 allows the Minister to prescribe standards
for delivering services in those facilities by regional health
authorities and health care organizations that have entered into
service agreements with a regional health authority.
The Act sets out the accountability requirements for regional
health authorities and health care organizations. These
requirements include submitting annual financial and
health service plans for ministerial approval (section 51),
establishing community advisory networks (section 28), and
reporting critical incidents (section 58). The Minister also has
the authority to establish a provincial surgical registry to help
manage surgical wait times (section 12). The Minister retains
authority to inquire into matters (section 59), appoint a public
administrator if necessary (section 60), and approve general
and staff practitioner by-laws (sections 42–44).
Funding for hospitals is included in the funding provided to
regional health authorities.
A comprehensive range of insured services is provided by
hospitals. These may include: public ward accommodation;
necessary nursing services; the use of operating room and case
room facilities; required medical and surgical materials and
appliances; x-ray, laboratory, radiological and other diagnostic
procedures; radiotherapy facilities; anaesthetic agents and the
use of anaesthesia equipment; physiotherapeutic procedures;
all drugs, biological and related preparations required for
hospitalized patients; and services rendered by individuals
who receive remuneration from the hospital.
Hospitals are grouped into the following five categories:
Community Hospitals; Northern Hospitals; District
Hospitals; Regional Hospitals; and Provincial Hospitals,
so people know what they can expect at each hospital.
While not all hospitals will offer the same kinds of services,
reliability and predictability means:
CHAPTER 3: SASKATCHEWAN
■■ it is widely understood which services each hospital offers;
and
■■ these services will be provided on a continuous basis, subject
to the availability of appropriate health providers.
Regional health authorities have the authority to change the
manner in which they deliver insured hospital services based
on an assessment of their population health needs, available
health providers and financial resources.
The process for adding a hospital service to the list of services
covered by the health care insurance plan involves a compre­
hensive review, which takes into account such factors as service
need, anticipated service volume, health outcomes by the
proposed and alternative services, cost and human resource
requirements, including availability of providers as well as
initial and ongoing competency assurance demands. A regional
health authority initiates the process and, depending on the
specific service request, it could include consultations involving
several branches within the Ministry of Health as well as
external stakeholder groups such as other regional health
authorities, service providers and the public.
2.2 Insured Physician Services
Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act
enable the Minister of Health to establish and administer a plan
of medical care insurance for provincial residents. All fee items
for physicians can be found in the Physician Payment Schedule
at www.saskatchewan.ca.
As of March 31, 2015, there were 2,224 physicians licensed to
practice in the province and eligible to participate in the Medical
Care Insurance Plan. Of these, 1,181 (53.1 percent) were family
practitioners and 1,043 (46.9 percent) were specialists.
Physicians may opt out or not participate in the Medical
Services Plan, but if doing so, they must fully opt out of all
insured physician services. The opted-out physician must also
advise beneficiaries that the physician services to be provided
are not insured and that the beneficiary is not entitled to be
reimbursed for those services. Written acknowledgement from
the beneficiary indicating that he or she understands the advice
given by the physician is also required.
As of March 31, 2015, there were no opted-out physicians
in Saskatchewan.
Insured physician services are those that are medically necessary,
are covered by the Medical Services Plan of the Ministry of
Health, and are listed in the Physician Payment Schedule of the
Saskatchewan Medical Care Insurance Payment Regulations
(1994) of the Saskatchewan Medical Care Insurance Act.
A process of formal discussion between the Medical Services
Plan and the Saskatchewan Medical Association addresses new
insured physician services and definition or assessment rule
revisions to existing selected services. The Executive Director
of the Medical Services Branch manages this process. When
the Medical Services Plan covers a new insured physician
service, or revisions to definitions or assessment rules for
existing services occur, a regulatory amendment is made
to the Physician Payment Schedule.
Although formal public consultations are not held, any member
of the public may make recommendations about physician
services to be added to the Medical Services Plan.
2.3 Insured Surgical-Dental Services
Dentists may opt out or not participate in the Medical Services
Plan, but if doing so, they must opt out of all insured surgicaldental services. The dentist must also advise beneficiaries that
the surgical-dental services to be provided are not insured
and that the beneficiary is not entitled to reimbursement for
those services. Written acknowledgement from the beneficiary
indicating that he or she understands the advice given by the
dentist is also required. There were no opted-out dentists in
Saskatchewan as of March 31, 2015.
Insured surgical-dental services are limited to: services in
connection with maxillo-facial surgery required as a result of
trauma; treatment services for the orthodontic care of cleft palate;
extraction of teeth when medically required for the provision
of heart surgery, services for chronic renal disease, head and
neck cancer services, and services for total joint replacement
by prosthesis when a formal referral has been made and prior
approval obtained from Medical Services Branch; and certain
services in connection with abnormalities of the mouth and
surrounding structures.
Surgical-dental services can be added to the list of insured
services covered under the Medical Services Plan through a
process of discussion and consultation with provincial dental
surgeons. The Executive Director of the Medical Services
Branch manages the process of adding a new service. Although
formal public consultations are not held, any member of the
public may recommend that surgical-dental services be added
to the Medical Services Plan.
As of March 31, 2015, there were approximately 473 practicing
dentists and dental surgeons located in all major centres in
Saskatchewan. Seventy-nine provided services insured under
the Medical Services Plan.
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CHAPTER 3: SASKATCHEWAN
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
3.0UNIVERSALITY
Uninsured hospital, physician and surgical-dental services
in Saskatchewan include: in-patient and out-patient hospital
services provided for reasons other than medical necessity; the
extra cost of private and semi-private hospital accommodation
not ordered by a physician; physiotherapy and occupational
therapy services not provided by or under contract with a
regional health authority; services provided by health facilities
other than hospitals unless through an agreement with a
regional health authority and licensed under the Health
Facilities Licensing Act; non-emergency insured hospital,
physician or surgical-dental services obtained outside Canada
without prior written approval; non-medically required
elective physician services; surgical-dental services that are
not medically necessary; and services received under other
public programs including the Workers’ Compensation Act, the
federal Department of Veteran Affairs and the Mental Health
Services Act.
3.1Eligibility
As a matter of policy and principle, insured hospital, physician
and surgical-dental services are provided to residents on the basis
of assessed clinical need. Compliance is periodically monitored
through consultation with regional health authorities, physicians
and dentists. There are no charges allowed in Saskatchewan for
insured hospital, physician or surgical-dental services. Charges
for enhanced medical services or products are permitted only if
the medical service or product is not deemed medically necessary.
Compliance is monitored through consultations with regional
health authorities, physicians and dentists.
Insured hospital services could be de-insured by the government
if they were determined to be no longer medically necessary.
The process is based on discussions among regional health
authorities, practitioners, and officials from the Ministry
of Health.
Insured physician services could be de-insured if they were
determined not to be medically required. The process is based
on consultations with the Saskatchewan Medical Association
and managed by the Executive Director of the Medical
Services Branch.
Insured surgical-dental services could be de-insured if they
were determined not to be medically necessary. The process is
based on discussion and consultation with the dental surgeons
of the province, and is managed by the Executive Director of
the Medical Services Branch.
Formal public consultations about de-insuring hospital, physician
or surgical-dental services may be held if warranted. There were
no services de-insured in 2014–2015.
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The Saskatchewan Medical Care Insurance Act (sections 2 and 12)
and the Medical Care Insurance Beneficiary and Administration
Regulations define eligibility for insured health services in
Saskatchewan. Section 11 of the Act requires that all residents
register for provincial health coverage.
Eligibility is limited to residents. A “resident” means a person
who is legally entitled to remain in Canada, who makes his
or her home and is ordinarily present in Saskatchewan, or any
other person declared by the Lieutenant Governor-in-Council
to be a resident. Canadian citizens and permanent residents
of Canada relocating from within Canada to Saskatchewan
are generally eligible for coverage on the first day of the third
month following establishment of residency in Saskatchewan.
Returning Canadian citizens, the families of returning members
of the Canadian Forces, international students, and international
workers are eligible for coverage on establishing residency in
Saskatchewan, provided that residency is established before
the first day of the third month following their admittance
to Canada.
The following persons are not eligible for insured health services
in Saskatchewan:
■■ members of the Canadian Forces, federal inmates, refugee
claimants, visitors to the province; and
■■ persons eligible for coverage from their home province
or territory for the period of their stay in Saskatchewan
(e.g., students and workers covered under temporary
absence provisions from their home province or territory).
Such people become eligible for coverage as follows:
■■ discharged members of the Canadian Forces, if stationed in
or resident in Saskatchewan on their discharge date;
■■ released federal inmates (this includes those prisoners who
have completed their sentences in a federal penitentiary and
those prisoners who have been granted parole and are living
in the community); and
■■ refugee claimants, on receiving Convention Refugee status
(immigration documentation is required).
The number of persons registered for health services in
Saskatchewan on June 30, 2014, was 1,152,330.
CHAPTER 3: SASKATCHEWAN
3.2 Other Categories of Individuals
Other categories of individuals who are eligible for insured
health service coverage include persons allowed to enter
and remain in Canada under authority of a work permit,
study permit or Minister’s permit issued by Citizenship and
Immigration Canada. Their accompanying family may also
be eligible for insured health service coverage.
Refugees are eligible on confirmation of Convention status
combined with a study or work permit, Minister’s permit or
permanent resident or landed immigrant record.
4.0PORTABILITY
4.1 Minimum Waiting Period
In general, insured persons from another province or territory
who move to Saskatchewan are eligible on the first day of the
third month following establishment of residency. However,
where one spouse arrives in advance of the other, the eligibility
for the later arriving spouse is established on the earlier of a)
the first day of the third month following arrival of the second
spouse; or b) the first day of the thirteenth month following the
establishment of residency by the first spouse.
4.2 Coverage During Temporary Absences
in Canada
Section 3 of the Medical Care Insurance Beneficiary and
Administration Regulations of the Saskatchewan Medical Care
Insurance Act prescribes the portability of health insurance
provided to Saskatchewan residents while temporarily absent
within Canada. There were no changes to the in-Canada
temporary absence provisions in 2014–2015.
Section 6.6 of the Health Administration Act provides
the authority for paying in-patient hospital services to
Saskatchewan beneficiaries temporarily residing outside the
province. Section 10 of the Saskatchewan Medical Care
Insurance Payment Regulations (1994) provides payment for
physician services to Saskatchewan beneficiaries temporarily
residing outside the province.
Continued coverage during a period of temporary absence
is conditional upon the registrant’s intent to return to
Saskatchewan residency immediately on expiration of
the approved absence period as follows:
■■ education: for the duration of studies at a recognized
educational facility (confirmation by the facility of full-time
student status and expected graduation date are required);
■■ employment of up to 12 months (no documentation
required); and
■■ vacation and travel of up to 12 months.
Saskatchewan has bilateral reciprocal billing agreements with
all provinces for hospital services. Quebec does not participate
in reciprocal billing of physician services.
4.3 Coverage During Temporary Absences
Outside Canada
Section 3 of the Medical Care Insurance Beneficiary and
Administration Regulations of the Saskatchewan Medical Care
Insurance Act prescribes the portability of health insurance
provided to Saskatchewan residents who are temporarily absent
from Canada.
Continued coverage for students, temporary workers, vacationers
and travelers during a period of temporary absence from
Canada is conditional on the registrant’s intent to return to
Saskatchewan residence immediately on the expiration of the
approved period as follows:
■■ education: for the duration of studies at a recognized
educational facility (confirmation by the facility of full-time
student status and expected graduation date are required);
■■ contract employment of up to 24 months; and
■■ vacation and travel of up to 12 months.
Section 3 of the Medical Care Insurance Beneficiary and
Administration Regulations provides open-ended temporary
absence coverage for persons whose principal place of residence
is in Saskatchewan, but who are not able to satisfy the annual
six months physical presence requirement because the nature
of their employment requires travel from place to place outside
Canada (e.g., cruise line workers).
Section 6.6 of the Health Administration Act provides the
authority under which a resident is eligible for health coverage
when temporarily outside Canada. In summary, a resident is
eligible for medically necessary hospital services at the rate of
$100 per in-patient and $50 per out-patient visit per day.
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CHAPTER 3: SASKATCHEWAN
4.4 Prior Approval Requirement
Out-of-Province
The Saskatchewan Ministry of Health covers most hospital and
medical out-of-province care received by its residents in Canada
through reciprocal billing arrangements. These arrangements
mean that residents do not need prior approval and may not be
billed for most services received in other provinces or territories
while travelling within Canada. The cost of travel, meals and
accommodation are not covered.
Prior approval is required for the following services provided
out-of-province:
■■ alcohol and drug, mental health, rehabilitation,
problem gambling services, home care, and certain
rehabilitative services.
Prior approval from the Ministry must be obtained by the
patient’s specialist.
If a specialist physician refers a patient outside Canada for
treatment not available in Saskatchewan or another province,
the referring specialist must seek prior approval from the
Medical Services Plan of the Ministry of Health. The
Saskatchewan Cancer Agency is consulted for out-of-country
cancer treatment requests. If approved, the Ministry of Health
will pay the full cost of treatment, excluding any items that
would not be covered in Saskatchewan.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
To ensure that access to insured hospital, physician and surgicaldental services are not impeded or precluded by financial barriers,
extra-billing by physicians or dental surgeons, and user charges
by hospitals for insured health services are not allowed in
Saskatchewan.
Building on the success of the Saskatchewan Surgical Initiative
which significantly reduced patient wait times for surgery,
the health system is working to strengthen coordination,
communication, and referral guidelines to better coordinate
services to ensure patients have timely access to the most
appropriate specialist and diagnostic services. By reducing
the wait time for a consult with a specialist or diagnostic
services (such as MRI and CTs), patients will be able to
access treatment sooner.
CANADA HEALTH ACT
■■ The provincial plan for distributed medical education
continued to be developed and rolled out with the
goal of increasing the number of medical seats in rural
centres. Post-graduate seats were offered in Regina,
Prince Albert, Swift Current, North Battleford,
La Ronge and Moose Jaw.
■■ The Physician Recruitment Agency of Saskatchewan
(saskdocs), created in 2009, continued to provide recruitment expertise to communities, physician practices and
health agencies.
■■ The Saskatchewan International Physician Practice
Assessment program worked to ensure that foreign-trained
physicians were assessed with sufficient rigor and patients
received safe, high-quality care.
Other Programs
Out-of-Country
90
In May 2009, the Government of Saskatchewan released
the Physician Recruitment Strategy in an effort to address
province-wide physician shortages. In 2014–2015 funding
supported several recruitment initiatives:
ANNUAL REPORT 2014–2015
The Family Physician Comprehensive Care Program is
intended to support recruitment and retention of family
physicians by recognizing those physicians who provide
a full range of services to their patients and the continuity
of care that result from these comprehensive services.
5.2 Physician Compensation
Section 6 of the Saskatchewan Medical Care Insurance
Payment Regulations (1994) outlines the obligation of the
Minister of Health to make payments for insured services
in accordance with the Physician Payment Schedule and the
Dentist Payment Schedule.
Fee-for-service is the most widely used method of
compensating physicians for insured health services in
Saskatchewan, although sessional payments, salary, and
blended methods are also used. Fee-for-service is the only
mechanism used to fund dentists for insured surgical-dental
services. Total expenditures for in-province physician services
and programs in 2014–2015 amounted to $898.6 million:
$507.1 million for fee-for-service billings; $30.4 million for
Specialist Emergency Coverage Programs; and $361.1 million
in non-fee-for-service expenditures. There was also an
additional $64.3 million for other Saskatchewan Medical
Association and bursary programs.
CHAPTER 3: SASKATCHEWAN
5.3 Payments to Hospitals
Funding to regional health authorities is based on historical
funding levels adjusted for inflation, collective agreement costs
and utilization increases. Each regional health authority is
given a global budget and is responsible for allocating funds
within that budget to address service needs and priorities
identified through its needs assessment processes.
Regional health authorities may receive additional funds for
providing specialized hospital programs (e.g., renal dialysis,
specialized medical imaging services, specialized respiratory
services, and surgical services), or for providing services to
residents from other health regions.
Payments to regional health authorities for delivering services are
made pursuant to section 8 of the Regional Health Services Act.
The legislation provides the authority for the Minister of Health
to make grants to regional health authorities and health care
organizations for the purposes of the Act, and to arrange for
providing services in any area of Saskatchewan if it is in the
public interest to do so.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
The Government of Saskatchewan publicly acknowledged the
federal contributions provided through the Canada Health
Transfer in the Ministry’s 2014–2015 Annual Report, the
Government of Saskatchewan 2014–2015 Budget and related
documents, its 2014–2015 Public Accounts, and the Quarterly
and Mid-Year Financial Reports. These documents were
tabled in the Legislative Assembly and are publicly available to
Saskatchewan residents. Federal contributions have also been
acknowledged on the Ministry of Health website, in news
releases and issue papers, and in speeches and remarks made
at various conferences, meetings and public policy forums.
Regional health authorities provide an annual report on the
aggregate financial results of their operations.
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CHAPTER 3: SASKATCHEWAN
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1,070,477
1,084,127
1,090,953
1,121,755
1,152,330
1
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#).
5. Payments to private for-profit facilities
for insured health services ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
66
66
66
66
66
1,636,013,000
2
1,694,858,000
2
1,777,208,000
2
1,846,795,000
2
1,889,855,000
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
3
5
4
4
4
Not Available
3
Not Available
3
Not Available
3
Not Available
3
Not Available
2
3
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4,304
5,258
5,433
4,845
4,113
48,700,300
51,418,800
54,483,700
53,004,700
42,834,000
67,689
65,916
74,201
67,387
66,006
21,282,400
22,268,800
26,716,300
24,736,300
24,130,100
4
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
295
400
388
374
358
3,401,000
8,186,600
2,007,000
2,271,900
4,529,900
1,992
2,646
1,938
1,730
1,488
1,796,700
3,203,800
1,511,300
1,606,100
480,300
5
1. Saskatchewan’s numbers as of June 30, 2014.
2. This number includes estimated government funding to regional health authorities in their annual audited financial statements.
– Includes acute care services, specialized hospital services, and in-hospital specialist services.
– Does not include inpatient mental mental health, or addiction treatment services.
– Does not include payments to Saskatchewan Cancer Agency for out-patient chemotherapy and radiation.
3. Private facilities providing surgical services and computed tomography scans receive payments for these services under contract with regional health authorities.
The Ministry of Health does not provide payments to these facilities.
4. Decrease in 2014–15 due to decrease in in-patient claims and corresponding mix of procedure cost.
5. Increase in 2011–12 was due to a cluster of high cost procedures Saskatchewan residents received in the United States.
6. Decrease in 2014–15 was due to a decrease in out-of-country treatments.
92
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6
CHAPTER 3: SASKATCHEWAN
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1,946
1,985
2,044
2,165
2,224
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of not participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($).
714,441,498
794,901,943
823,656,225
873,484,838
898,584,963
18.Total payments for services provided by
physicians paid through fee-for-service ($).
457,194,531
14.Number of participating physicians (#).
7
457,307,474
7
480,173,762
7
488,651,587
507,079,008
7
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
610,328
623,778
659,994
697,161
714,648
31,505,813
32,103,002
33,658,928
35,703,160
37,220,270
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
not available
not available
not available
not available
not available
1,324,100
2,279,100
1,199,100
1,484,200
1,416,300
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
85
93
88
82
79
17,800
17,420
18,123
16,014
17,346
1,827,088
1,719,770
1,710,397
1,669,803
1,870,512
7. Figure is composed of fee-for-service billing and funding for the Emergency Rural Coverage Program which is paid through the fee-for-service program.
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7
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ALBERTA
INTRODUCTION
Alberta’s Health Care System
The Minister of Health, the Department of Health (Alberta
Health) and the Regional Health Authority (Alberta Health
Services) play key roles in Alberta’s health care system. All
entities work together to deliver better care, improve health
outcomes and provide the best health care system possible
for Albertans.
The vision of Alberta Health; Healthy Albertans in a Healthy
Alberta, is achieved through a commitment to the mission, core
business and goals of the ministry. Alberta Health’s mission
is to set policy and direction to improve health outcomes for
all Albertans, support the wellbeing and independence of
Albertans, and achieve a high quality, appropriate, accountable
and sustainable health system. Alberta Health’s core business
is improving Albertans’ health status over time.
Over the past year Alberta has made progress towards three key
desired outcomes:
Goal 2: Albertans have improved health as a result of
protecting and promoting wellness and supporting
independence
Over 1.2 million Albertans received the influenza vaccine in
2014–2015. This is 30 percent of the population, as compared
to 27 percent in 2013–2014. Pharmacists administered
486,709 doses of influenza vaccine and Alberta Health
Services Public Health administered 492,220 doses.
Reports show that 64 percent of Alberta Health Services
health care workers were immunized in the 2014–2015
influenza season, as compared to 60 percent in 2013–2014.
The Skin Cancer Prevention (Artificial Tanning) Act is a major
step forward in the effort to reduce cancer in Alberta. The bill
for this Act was passed in March 2015. When the legislation
is proclaimed in force and regulations completed, it will:
■■ ban businesses from selling and providing artificial tanning
services to minors;
■■ prohibit advertising of artificial tanning directed to minors;
■■ mandate health warnings in artificial tanning facilities and
on advertising materials; and
Goal 1: Strengthened health system leadership,
accountability and performance
■■ prohibit unsupervised, self-serve artificial tanning equipment
Each year approximately 1,600 medical residents train through
Alberta’s two medical schools and over 300 undergraduate
medical students commence their medical studies. Medical
residents provide direct clinical services during their two to
eight years of training. Approximately 70 percent of Alberta’s
medical graduates set up practice in Alberta, which is the
second highest retention rate in Canada.
Goal 3: Albertans have enhanced access to high
quality, appropriate, cost-effective health care
and support services
in public places.
The government is committed to providing the support needed
to improve evolving primary care delivery that responds to the
health care needs of Albertans. Alberta’s Primary Health Care
Strategy, released in May 2014, sets the direction for Primary
Health Care transformation and reinforces the vision for
Albertans to be as healthy as they can be.
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CHAPTER 3: ALBERTA
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
Alberta Health administers and operates the Alberta Health
Care Insurance Plan in accordance with the Canada Health Act.
Since 1969, the Alberta Health Care Insurance Act has governed
the operation of the Alberta Health Care Insurance Plan.
The Minister of Health, working in conjunction with the
appropriate stakeholders, determines which services are covered
by the Alberta Health Care Insurance Plan.
1.2 Reporting Relationship
The Minister of Health is accountable for the Alberta Health
Care Insurance Plan. The Fiscal Management Act, which came
into force in 2013, provides a framework to govern budgeting
and fiscal planning.
The publicly funded services provided by approved hospitals in
Alberta range from the most advanced levels of diagnostic and
treatment services for in-patients and out-patients, to routine
care and management of patients with previously diagnosed
chronic conditions. The benefits available to hospital patients
in Alberta are established in the Hospitalization Benefits
Regulation (AR 244/1990). The Regulation is available at:
www.health.alberta.ca/about/health-legislation.html.
There is no regular process to review insured hospital services,
as the list of insured services included in the regulations is
intended to be both comprehensive and generic, and does
not require routine review and updating. Changes to specific
physician services can be found in the Schedule of Medical
Benefits, and are described in the next section.
2.2 Insured Physician Services
1.3 Audit of Accounts
The Alberta Health Care Insurance Act governs the payment of
physicians for insured physician services under the Alberta
Health Care Insurance Plan (section 6). Only physicians who
meet the requirements stated in the Act are permitted to make
a claim for payment of benefits for providing insured services
under the Alberta Health Care Insurance Plan.
The Auditor General of Alberta audits all government
ministries, departments, regulated funds and provincial
agencies, and is responsible for assuring the public that the
government’s financial reporting is credible. The Auditor
General of Alberta completed an audit of Alberta Health on
June 5, 2015 and indicated that the statements fairly represent,
in all material respects, the financial position and results of
operations for the year that ended March 31, 2015.
Alberta had 8,873 physicians participating under the Alberta
Health Care Insurance Plan as of March 31, 2015. Within this,
7,405 physicians were paid exclusively under fee-for-service,
697 were compensated solely under an Alternative Relationship
Plan (ARP) and the remaining 771 physicians received
compensation from both fee-for-service and ARP. Out of the
4,537 General Practitioners, 3,284 were registered providers
in Primary Care Networks as of March 31, 2015.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
In Alberta, Alberta Health Services is the body responsible to
the Minister of Health for ensuring the provision of insured
hospital services. The Hospitals Act, the Hospitalization
Benefits Regulation (AR 244/1990), the Health Care
Protection Act, and the Health Care Protection Regulation
(AR 208/2000) govern the provision of insured services
by hospitals or designated non-hospital surgical facilities.
A directory of approved hospitals in Alberta can be found at:
www.health.alberta.ca/services/health-benefits-services.html.
During 2014–2015, no amendments were made to the legislation
regarding insured hospital services.
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Before being registered with the Alberta Health Care Insurance
Plan, a physician must complete the appropriate registration
forms and include a copy of his or her license issued by the
College of Physicians and Surgeons of Alberta.
Under section 8 of the Alberta Health Care Insurance Act, all
physicians are deemed to be opted into the Alberta Health
Care Insurance Plan. A physician may; however, opt out by
notifying the Minister they wish to opt out of the Alberta
Health Care Insurance Plan. Under section 8(2) a physician
may opt out of the Plan by (a) notifying the Minister in writing
indicating the effective date of the opting out, (b) publishing
a notice of the proposed opting out in a newspaper having
general circulation in the area in which the physician practices,
and (c) posting a notice of the proposed opting out in a part
of the physician’s office to which patients have access at least
180 days prior to the effective date of the opting out. By opting
out of the Alberta Health Care Insurance Plan, a physician
agrees that, commencing on the opt-out effective date, they
will not participate in the publicly funded health system.
CHAPTER 3: ALBERTA
This means that the physician cannot make a claim from the
Alberta Health Care Insurance Plan for payment for providing
what would otherwise be publicly funded health services and
the patient cannot seek reimbursement for any amounts paid
by the patient for receiving health services from the opted-out
physician. As of July 1, 2014, one physician opted out of the
Alberta Health Care Insurance Plan in the province.
Section 12 of the Alberta Health Care Insurance Regulation
lists services which are not considered as basic or extended
health services. The Medical Benefits Regulation establishes
the benefits payable for insured medical services provided to a
resident of Alberta. Descriptions of those services are set out
in the Schedule of Medical Benefits, which can be accessed at:
www.health.alberta.ca/professionals/SOMB.html.
2.3 Insured Surgical-Dental Services
In Alberta, a small number of surgical-dental services are
insured. The majority of dental procedures that can be billed to
the Alberta Health Care Insurance Plan can only be performed
by a dentist certified as an oral and maxillofacial surgeon
who meets the requirements stated in the Alberta Health Care
Insurance Act.
Alberta insures a number of medically necessary oral surgical
and dental procedures that are listed in the Schedule of Oral
and Maxillofacial Surgery Benefits, available at: www.health.
alberta.ca/professionals/allied-services-schedule.html.
Although there is no formal agreement with dentists, Alberta
Health meets with members of the Alberta Dental Association
and College to discuss changes to the Schedule of Oral and
Maxillofacial Surgery Benefits. All changes to the benefit
schedule require Ministerial approval.
Under section 7 of the Alberta Health Care Insurance Act, all
dentists are deemed to have opted into the Plan. A dentist may
opt out by notifying the Minister of Health they wish to opt
out of the Alberta Health Care Insurance Plan.
Under section 7(2) a dentist may opt out of the Plan by
(a) notifying the Minister in writing indicating the effective
date of the opting out, (b) publishing a notice of the proposed
opting out in a newspaper having general circulation in the
area in which the dentist practices, and (c) posting a notice
of the proposed opting out in a part of the dentist’s office to
which patients have access at least 30 days prior to the effective
date of the opting out. By opting out of the Alberta Health
Care Insurance Plan, a dentist agrees that, commencing on
the opt-out effective date, they will not participate in the
publicly funded health system. This means that the dentist
cannot make a claim from the Alberta Health Care Insurance
Plan for payment for providing what would otherwise be
publicly funded surgical-dental services and the patient cannot
seek reimbursement for any amounts paid by the patient for
receiving surgical-dental services from the opted-out dentist.
As of March 31, 2015, no dentists were opted-out of the
Alberta Health Care Insurance Plan.
2.4 Uninsured Hospital, Physician, and
Surgical-Dental Services
Section 12 of the Alberta Health Care Insurance Regulation
lists services which are not considered as basic or extended
health services. Section 4(2) of the Hospitalization Benefits
Regulation provides a list of hospital services that are not
considered to be insured.
The Preferred Accommodation and Non Standard Goods
or Services Policy describes the Government of Alberta’s
expectations of Alberta Health Services and guides the
provision of preferred accommodation, and enhanced or nonstandard goods and services. This policy framework requires
Alberta Health Services to provide 30 days advance notice to
the Health Minister’s designate regarding the categories of
preferred accommodation offered and the charges associated
with each category. Alberta Health Services is also required
to provide 30 days advance notice to the Health Minister’s
designate regarding any goods or services that will be provided
as non-standard goods or services. Alberta Health Services
must also provide information about the associated charge
for these goods or services, and when applicable, the criteria
or clinical indications that may qualify patients to receive it
as a standard good or service. Alberta’s policy for Preferred
Accommodation and Non-Standard Goods or Services is
available at: www.health.alberta.ca/documents/preferredaccommodation-policy-2005.pdf.
3.0UNIVERSALITY
3.1Eligibility
Under the terms of the Alberta Health Care Insurance Act,
Alberta residents are eligible to receive publicly funded health
care services under the Alberta Health Care Insurance Plan.
A resident is defined as a person lawfully entitled to be or to
remain in Canada, who makes the province his or her home and
is ordinarily present in Alberta as defined in the regulations.
The term “resident” does not include a tourist, transient, or
visitor to Alberta. Persons moving permanently to Alberta from
outside Canada are eligible for coverage if they have permanent
resident status, are returning landed immigrants, or are returning
Canadian citizens. Persons in Alberta on an approved Canada
entry permit may also be eligible for coverage under the Alberta
Health Care Insurance Plan, and their eligibility is reviewed on
a case-by-case basis.
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CHAPTER 3: ALBERTA
Certain categories of individuals who would otherwise be
considered residents are deemed by the Alberta Health Care
Insurance Act to be eligible for coverage received under federal
legislation. These residents who are not eligible for coverage
under the Alberta Health Care Insurance Plan, but receive
health care coverage from the federal government, include:
■■ members of the Canadian Armed Forces; and
■■ persons serving a term in a federal penitentiary.
Spouses or partners and dependents of the above are provided
with Alberta Health Care Insurance Plan coverage if they are
Alberta residents.
The Alberta Health Care Insurance Plan will cover individuals
released from the Canadian Armed Forces, and federal
penitentiaries, effective the date of release, if notified within
three months. If they are released in another part of Canada,
they are eligible for coverage on the first day of the third
month after becoming a resident of Alberta. The RCMP Health
Coverage Statutes Amendment Act provides Royal Canadian
Mounted Police members coverage under the Alberta Health
Care Insurance Plan.
In order to access insured services under the Alberta Health
Care Insurance Plan, Alberta residents are required to register
themselves and their eligible dependents. Family members are
registered on the same account. Persons moving to Alberta
should apply for coverage within three months of arrival or
effective dates may be affected. For persons moving to Alberta
from within Canada, their registration is effective on the first
day of the third month after their arrival. For persons moving
to Alberta from outside Canada, their registration is effective
the day they become an Alberta resident. The Alberta Health
Care Insurance Plan process, for registering Albertans and
issuing replacement health cards, requires registrants to provide
documentation that proves their identity, legal entitlement
to be in Canada, and Alberta residency.
As of March 31, 2015, there were 4,354,660 Alberta residents
registered with the Alberta Health Care Insurance Plan. Under
the Health Insurance Premiums Act, a resident may opt out of
the Alberta Health Care Insurance Plan by filing a declaration
with the Minister of Health. As of March 31, 2015, there were
249 Alberta residents who were opted out of the Plan.
3.2 Other Categories of Individuals
Certain categories of individuals with an approved Canada
entry permit may also be eligible for coverage. These
include individuals with Student or Employment Permits,
Temporary Resident Permits, and Visitor Records. There
were 104,335 people covered under these conditions as of
March 31, 2015.
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4.0PORTABILITY
4.1 Minimum Waiting Period
Under the Alberta Health Care Insurance Plan, generally
persons moving permanently to Alberta from another part of
Canada are eligible for coverage on the first day of the third
month following their arrival.
4.2 Coverage During Temporary Absences
in Canada
The Alberta Health Care Insurance Plan provides coverage
for eligible Alberta residents who temporarily leave Alberta
for other parts of Canada. A person is considered temporarily
absent from Alberta if the person stays in another province or
territory for a period that will not exceed 12 consecutive months.
Individuals who are routinely absent from Alberta every
year normally must spend a cumulative total of 183 days in a
12 month period in Alberta to maintain continuous coverage.
Individuals not present in Alberta for the required 183 days
may be considered residents of Alberta if they satisfy Alberta
Health of their permanent and principal place of residence
within the province. Individuals may also remain eligible
for coverage if, on a recurring basis, they are absent from
Alberta for up to 212 days in 12 month period for the purpose
of vacation.
Alberta participates in the interprovincial hospital and medical
reciprocal billing agreements. All provinces and territories
except Quebec participate in medical reciprocal agreements.
These agreements were established to minimize complex billing
processes and to help ensure timely payments to physicians
and hospitals when they provide services to residents from
other provinces or territories. Under these agreements, where
an eligible Albertan receives an insured physician service or
hospital service in another participating province or territory,
Alberta will reimburse for the insured service provided at the
host province’s or territory’s rates for that insured service.
In 2014–2015, no amendments were made to the legislation
regarding portability in Canada. More information on coverage
during temporary absences outside Alberta is available at:
www.health.alberta.ca/AHCIP/outside-coverage.html.
Section 16 of the Hospitalization Benefits Regulation addresses
payment for hospital services obtained outside of Alberta but
within Canada. Section 4 of the Medical Benefits Regulation
addresses payment of physician services obtained outside of
Alberta but within Canada. These sections were not amended
in 2014–2015.
CHAPTER 3: ALBERTA
4.3 Coverage During Temporary Absences
Outside Canada
The Alberta Health Care Insurance Plan provides coverage
to eligible Alberta residents who are temporarily absent from
Canada. A person is considered to be temporarily absent from
Alberta if the person stays outside Canada for a period that will
not exceed six consecutive months, and the person intends to
return to and maintain permanent residence in Alberta on the
conclusion of their stay outside Alberta.
Individuals who are routinely absent from Alberta every
year normally must spend a cumulative total of 183 days in a
12 month period in Alberta to maintain continuous coverage.
Individuals not present in Alberta for the required 183 days
may be considered residents of Alberta if they satisfy Alberta
Health of their permanent and principal place of residence
within the province. Individuals may also remain eligible
for coverage if, on a recurring basis, they are absent from
Alberta for up to 212 days in 12 month period for the purpose
of vacation.
Individuals leaving the province temporarily on extended
vacations, or for temporary employment, may be eligible
for coverage for 24 to 48 consecutive months. They should
contact Alberta Health to enquire about their coverage. Students
attending an accredited educational institute on a full-time basis
are entitled to coverage for the duration of their studies.
The maximum amount payable for out-of-country in-patient
hospital services is $100 (Canadian) per day (not including
day of discharge). The maximum hospital out-patient visit rate
is $50 (Canadian), with a limit of one visit per day. The only
exception is haemodialysis received as an out-patient, which
until March 31, 2015, was paid at a maximum of $423 per
visit, with a limit of one visit per day. Effective April 1, 2015,
the rate increased from $423 to $453 per visit. Physician and
dental specialist/oral surgeon services are paid according to
Alberta rates. Funding may also be available through the
Out-of-Country Health Services Committee process that will
evaluate reimbursement requests made by Alberta physicians
or dentists for eligible Alberta residents for medically necessary
services covered under the Alberta Health Care Insurance
Plan, and received in an emergency situation or that were
not available in Canada. More information on coverage
during temporary absences outside Canada is accessible at:
www.health.alberta.ca/AHCIP/outside-coverage.html.
Section 16 of the Hospitalization Benefits Regulation addresses
payment for hospital services obtained outside of Canada.
Section 5 of the Medical Benefits Regulation addresses
payment of physician services obtained outside Canada.
These sections were not amended in 2014–2015.
4.4 Prior Approval Requirement
Prior approval is not required for elective insured services
received in another Canadian province or territory, except for
high-cost items not included in reciprocal agreements such as
gamma knife surgery.
Prior application is required for elective services received
out-of-country and approval may only be given through the
Out-of-Country Health Services Committee for insured
services that are medically required, are not experimental,
and are not available in Alberta or elsewhere in Canada.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
The Ministries of Health and Infrastructure have the
responsibilities for planning and management of the Health
Facilities Capital Program and projects. The Ministry of Health
is responsible for setting strategic directions and implementing
health policy, legislation, standards and providing the global
operating funding to Alberta Health Services (AHS) for
the provision of provincial health services. Alberta Health
Services identifies and prioritizes health service needs requiring
capital development. The Government of Alberta supports
health infrastructure by funding capital development and
the infrastructure maintenance program. The Ministry of
Infrastructure is responsible for the design, construction
and delivery of major health capital projects throughout the
province. The Ministry of Infrastructure is currently leading
major health capital projects in High Prairie, Grande Prairie,
Edson, Edmonton, Calgary, Red Deer, Medicine Hat,
Taber, Lethbridge and Raymond. Health legislation also
stipulates the requirements for the purchase and disposition
of assets and properties and the general provisions for health
infrastructure. More information on capital plans is available
at: http://finance.alberta.ca/publications/budget/budget2015october/fiscal-plan-capital-plan.pdf.
5.2 Physician Compensation
The Alberta Health Care Insurance Act governs the payment of
physicians. Physicians are compensated through the Alberta
Health Care Insurance Plan on a volume-driven, fee-for-service
basis or through the use of Alternative Relationship Plans
(ARPs). ARPs are used by specialists and family physicians
and offer alternative compensation models to the fee-for-service
payment system. The goal of ARPs is to contribute to better
health outcomes by supporting innovative health care delivery.
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The purpose of ARPs is to enhance physician recruitment and
retention, team-based approaches to service delivery, access
to services, patient satisfaction, and value for money. ARPs
provide predictable funding that enables physician groups
to recruit new physicians to their programs and retain their
services while in some cases additional funding is provided
to support this service delivery approach. ARPs are unique
in that they offer an alternative funding model to the way
government has traditionally funded health care service
delivery by physicians.
According to the Health Care Protection Act, Ministerial
approval for a service agreement shall not be given unless:
Alberta Health and the Alberta Medical Association entered
into the Alberta Medical Association Agreement (AMAA)
in 2013, which was retroactive to April 1, 2011. The financial
terms of the AMAA establish set increases to the insured
services rates for seven years (from 2011 to 2018), and Alberta
Health and the Alberta Medical Association will negotiate new
financial terms for April 1, 2018 onwards.
■■ there will be an expected benefit to the public;
The Ministry also funds Primary Care Networks (PCNs) in
which family physicians work with AHS to improve access to
primary care and increase the availability of multi‑disciplinary
teams and chronic disease management. PCNs receive per‑capita
payments in order to enhance or add services, including funding
other health care providers and offering programs. Each PCN
decides how funds will be allocated based on alignment with
PCN policy and approved business plans.
5.3 Payments to Hospitals
The Regional Health Authorities Act governs the funding
of Alberta’s single regional health authority; AHS. The
provision of insured health services by AHS is funded
through a single base operating grant. Funding is provided
for insured services delivered in hospitals and designated
non-hospital surgical facilities.
Alberta’s Health Care Protection Act governs the provision of
insured and uninsured surgical services performed in public
hospitals and in Non-Hospital Surgical Facilities (NHSFs.).
Ministerial approval of a service agreement between the facility
operator and AHS is required in order for the facility to provide
insured surgical services. Ministerial designation of a NHSF
and accreditation by the College of Physicians and Surgeons
of Alberta is also required.
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■■ the insured surgical services are consistent with the principles
of the Canada Health Act;
■■ there is a current and likely future need for the services
in the geographical area;
■■ the proposed surgical services will not have an adverse
impact on the province’s publicly funded and publicly
administered health system;
■■ AHS has an acceptable business plan to pay for the services;
■■ the proposed agreement contains performance expectations
and measures; and
■■ the physicians providing the services will comply with
the conflict of interest and ethical requirements of the
Health Professions Act and the bylaws of the College of
Physicians and Surgeons of Alberta.
Pursuant to the terms of any agreement as between AHS and a
facility operator, AHS agrees to pay a contracted “facility fee.”
This fee covers such costs as some staff salaries and benefits,
supplies, utilities, and other overhead costs. Physicians
who provide insured surgical services to patients within an
accredited NHSF are paid on a fee-for-service basis through
the Alberta Health Care Insurance Plan. These fees are the
same regardless of whether the physician provides the insured
service in a public hospital setting or in a NHSF.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
The Government of Alberta publicly acknowledged the federal
contributions provided through the Canada Health Transfer in
its 2014–2015 publications.
CHAPTER 3: ALBERTA
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
3,786,238
3,910,117
4,068,062
4,228,125
4,354,660
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
225
225
226
225
225
not available
not available
not available
not available
not available
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4. Number of private for-profit facilities
providing insured health services (#).
not available
not available
not available
not available
not available
5. Payments to private for-profit facilities
for insured health services ($).
not available
not available
not available
not available
not available
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY 1
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
5,689
5,707
5,657
6,221
6,297
37,887,391
36,659,355
37,628,241
42,196,441
42,466,396
110,757
109,703
112,703
119,873
127,995
29,382,381
29,687,993
31,763,550
35,627,462
37,809,358
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA1,2
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
3,075
3,613
4,921
4,209
3,679
294,509
339,343
472,489
393,925
359,377
3,425
4,414
5,461
5,128
4,440
267,120
467,081
440,188
487,055
419,295
1. Data reported for indicators 6 through 13 reflect claims processed up to three months after the close of the fiscal year. Any claims processed after this date are
not reflected in the presented information.
2. These data do not include claims/payments for Alberta residents who have received health services through the Out-of-Country Health Services Committee
application process.
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INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY 3
14.Number of participating physicians (#). 4
15.Number of opted-out physicians (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
6,743
7,706
8,100
8,466
8,873
5
0
6
not applicable
16.Number of not participating physicians (#).
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
0
6
6
0
0
6
6
0
0
0
1
1
not available
not available
not available
not available
not available
2,302,481,210
2,450,159,476
2,584,944,346
2,778,382,882
3,033,392,142
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
611,503
616,786
751,061
663,164
694,373
25,340,583
27,960,901
27,940,698
30,710,409
32,203,224
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA 7
21.Number of services (#).
22.Total payments ($).
15,654
42,643
8
39,317
8
33,804
8
not available
9
909,715
2,573,169
8
2,435,305
8
2,189,233
8
not available
9
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
207
218
224
218
221
21,052
20,784
23,014
24,995
28,443
5,747,026
6,293,750
7,077,327
7,317,869
8,208,000
3. Data for this section reflect claims processed up to three months after the close of the fiscal year. Any data pertaining to expenditures and physicians processed
after this date are not reflected in the presented information.
4. Starting in 2011–2012, and going forward, the physician count includes physicians who are fee-for-service, in Alternative Relationship Plans or receive compensation
from both fee-for-service and Alternative Relationship Plans. Prior year reflected physicians that were only paid under fee-for-service.
5 7,405 of these are paid under fee-for-service, 697 under an Alternative Relationship Plan and the remaining 771 received compensation from both fee-for-service
and alternative relationship plans.
6 Alberta’s legislation provides that all physicians are deemed to be participating in the Alberta Health Care Insurance Plan, unless they opt out in accordance with
the procedure set out in section 8 of the Alberta Health Care Insurance Act.
7 These data do not include Alberta residents who have received health services through the Out-of-Country Health Services Committee application process.
8 The 2011–2012 to 2013–2014 figures are calculated using a new methodology for capturing the out-of-country claim process. The change now includes a one year
lag from the fiscal year end to date of payment for more precise data.
9 Data for out of country physician services are still being processed for 2014–2015.
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BRITISH COLUMBIA
INTRODUCTION
British Columbia has a progressive and integrated health
system that includes insured services funded under the
Canada Health Act, services funded wholly or partially by
the Government of British Columbia and services regulated,
but not funded, by government. The Ministry of Health
(the Ministry) has overall responsibility for ensuring that
quality, appropriate, and timely health services are available
to all British Columbians.
To read more about British Columbia’s publicly funded health
system, please refer to the Ministry of Health 2015/16 —
2017/18 Service Plan:
http://bcbudget.gov.bc.ca/2015/sp/pdf/ministry/hlth.pdf
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
The Ministry sets goals, standards, and performance
agreements for provincial health service delivery and works
with the province’s six health authorities to provide quality,
appropriate, and timely health services to British Columbians.
Five regional health authorities deliver a full continuum of
health services to meet the needs of the population within
their respective geographic regions. A sixth health authority,
the Provincial Health Services Authority, is responsible
for managing the quality, coordination, and accessibility of
province-wide health programs and services. The Ministry
also works in partnership with the First Nations Health
Authority to improve the health status of First Nations
in British Columbia.
Most insured services are covered by the British Columbia
Medical Services Plan (MSP), which is administered by the
Ministry. MSP covers medically required services provided
by physicians and supplementary healthcare practitioners,
laboratory services, and diagnostic procedures. The Medicare
Protection Act (MPA) is the enabling legislation for MSP.
The purpose of the MPA is to preserve a publicly-managed
and fiscally sustainable healthcare system for British Columbia,
in which access to necessary medical care is based on need
and not on an individual’s ability to pay.
The Medical Services Commission (MSC) manages MSP on
behalf of the Government of British Columbia in accordance
with the MPA (section 3) and its Regulation. The function and
mandate of the MSC is to facilitate reasonable access to quality
medical care, healthcare, and diagnostic facility services for
British Columbians.
The MSC is a nine-member statutory body made up of three
representatives from the Government of British Columbia,
three representatives from Doctors of BC (formerly the
British Columbia Medical Association), and three members
from the public jointly nominated by Doctors of BC
and government.
General hospital services are insured in British Columbia;
however, this is not covered by MSP. General hospital services
are provided under the Hospital Insurance Act (section 8)
and its Regulation; the Hospital Act (section 4); and the
Hospital District Act (section 20).
1.2 Reporting Relationship
The Ministry provides information in the Annual Service
Plan Report on the performance of British Columbia’s
publicly funded health system. Tracking and reporting this
information is consistent with the Ministry’s strategic approach
to performance planning and reporting and is consistent with
requirements contained in the provincial Budget Transparency
and Accountability Act (2000).
The MSC is accountable to the Government of British Columbia
through the Minister of Health (the Minister); a report is
published annually for the prior fiscal year which provides
an annual accounting of the business of the MSC, its
subcommittees, and other delegated bodies. This report
is available at: www2.gov.bc.ca/gov/content/health/
practitioner-professional-resources/msp/publications
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1.3 Audit of Accounts
The Ministry is subject to audit of accounts and financial
transactions through:
■■ Internal Audit and Advisory Services (IAAS); the
government’s internal auditor. IAAS determines the scope
of the internal audits and timing of the audits. IAAS
reports can be located on the following website link:
www.fin.gov.bc.ca/ocg/ias/Audit_Reports.htm
■■ The Office of the Auditor General (OAG) of British Columbia
is responsible for conducting annual audits as well as special
audits and reports. The OAG reports its findings to the
Legislative Assembly. The OAG initiates its own audits
and determines the scope of its audits. The Select Standing
Committee on Public Accounts of the Legislative Assembly
reviews the recommendations of the OAG.
The OAG’s annual audit of the Ministry’s accounts and
financial transactions are reflected in the OAG’s overall review
and opinion related to the BC Public Accounts, which can
be found at the following website link: www.fin.gov.bc.ca/
ocg/pa/14_15/Public%20Accounts%2014-2015.pdf
The OAG’s special audits and reports can be located at the
following link: www.bcauditor.com/pubs
1.4 Designated Agency
Since 2005, the Ministry has contracted with MAXIMUS
Canada to deliver the operations of MSP and PharmaCare
(including responding to public inquiries, registering clients,
and processing medical and pharmaceutical claims from health
professionals). MAXIMUS Canada administers the province’s
medical and drug insurance plans under the Health Insurance
BC (HIBC) program. Policy and decision-making functions
remain with the Ministry.
HIBC submits monthly reports to the Ministry, reporting
performance on service levels to the public and healthcare
providers. HIBC also posts reports on its website on
the performance of key service levels. These reports
are available at: www2.gov.bc.ca/gov/content/health/
about-bc-s-health-care-system/partners/health-insurance-bc
HIBC processes payments against fee items approved by the
Ministry. The Ministry approves all payments before they
are released.
MSP requires premiums to be paid by eligible residents.
Revenue Services of British Columbia (RSBC) performs
revenue management services, including account management,
billing, remittance, and collection on behalf of the Province
of British Columbia (Ministry of Finance). The province
remains responsible for and retains control of all government
administered collection actions.
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RSBC is required to comply with all applicable laws,
including the:
■■ Ombudsman Act;
■■ Business Practices and Consumer Protection Act; and
■■ Financial Administration Act.
■■ Freedom of Information Legislation (i.e., Freedom of
Information and Protection of Privacy Act, including
FOIPPA Inspections; the Personal Information Protection
Act and the equivalent federal legislation, if applicable).
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
The Hospital Act and Hospital Act Regulation provide
authority for the Minister to designate facilities as hospitals,
to license private residential care hospitals, to approve the
bylaws of hospitals, to inspect hospitals, and to appoint a
public administrator. This legislation also establishes broad
parameters for the operation of hospitals.
The Hospital Insurance Act and the Hospital Insurance Act
Regulations provide the authority for the Minister to make
payments to health authorities for the purpose of operating
hospitals, outlines who is entitled to receive insured services,
and defines the “general hospital services” which are to be
provided as benefits.
Hospital services are insured when they are provided to a
beneficiary in a publicly funded hospital, and are deemed
medically required by the attending physician, midwife, nurse
practitioner, or oral and maxillofacial surgeon. There is no
scheduled or regular process to review insured hospital services
as the insured services included in the regulations are intended
to be inclusive. Uninsured services are referred to in section 2.4
of this report.
When medically required, the following are provided
to beneficiaries who are in-patients in an acute or
rehabilitation hospital:
■■ accommodation and meals at the standard level;
■■ necessary nursing service;
■■ drugs, biologicals, and related preparations which are
required by the patient and administered in hospital;
■■ laboratory and radiological procedures and related
interpretations;
■■ diagnostic procedures and the necessary interpretations,
as approved by the Minister;
CHAPTER 3: BRITISH COLUMBIA
■■ use of operating rooms, caserooms, anaesthetic facilities,
routine surgical supplies, and other necessary equipment
and supplies;
■■ use of radiotherapy facilities;
■■ use of physiotherapy facilities;
■■ services of a social worker;
■■ other rehabilitation services, including occupational and
speech therapy; and
■■ other required services approved by the Minister, provided
by persons who receive remuneration from the hospital.
When medically required, the following are provided as
benefits under the Hospital Insurance Act or the Medicare
Protection Act (MPA) to out-patients who are beneficiaries:
■■ emergency department services;
■■ diagnostic services (e.g., laboratory or radiological
procedures);
■■ use of operating room facilities;
■■ equipment and supplies used in medically necessary services
provided to the beneficiary, including anaesthetics, sterile
supplies, dressings, casts, splints, immobilizers, and bandages;
■■ meals required during diagnosis and treatment;
■■ drugs and medications administered in a medically necessary
service provided to the beneficiary; and
■■ any service provided by an employee of the hospital that
is approved by the Minister.
The services are provided to beneficiaries without charge, with
a few exceptions. Exceptions include: incremental charges for
preferred (but not medically required) medical/surgical supplies
and nonstandard accommodation (when not medically required
and standard accommodation is available), and daily fees for
residential care patients in extended care or general hospitals.
Some facilities providing residential care services (in this case,
the term “extended care” is often used) are regulated under
the Hospital Act. Health authorities and hospital societies are
required to follow Home and Community Care policies to
determine benefits in such cases.
2.2 Insured Physician Services
The range of insured physician services covered by the
Medical Services Plan (MSP) includes all medically
necessary diagnostic and treatment services. Insured
physician services are provided under the MPA. Section
13 provides that practitioners, including physicians and
healthcare professionals such as midwives, who are enrolled
with MSP and who render benefits to a beneficiary, are
eligible to be paid for services rendered in accordance
with the appropriate payment schedule.
Unless specifically excluded, the following medical services are
insured as MSP benefits under the MPA in accordance with the
Canada Health Act:
■■ medically required services provided to beneficiaries
(residents of British Columbia who are enrolled in MSP
in accordance with section 7 of the MPA) by a physician
enrolled with MSP; and
■■ medically required services performed in an approved
diagnostic facility under the supervision of an enrolled
physician.
To practice in British Columbia, physicians must be registered
and in good standing with the College of Physicians and
Surgeons of British Columbia. To receive payment for
insured services, they must be enrolled with MSP. In the
fiscal year 2014–2015, 10,411 physicians were enrolled with
MSP and received payments through fee-for-service (FFS).
In addition, some physicians practice solely on salary, receive
sessional payments, or are on contract (service agreements)
with the health authorities. Physicians paid by these alternative
mechanisms may also practice on a FFS basis.
Practitioners other than physicians and dentists who may enroll
and provide benefits under MSP include midwives, optometrists
and supplementary benefit practitioners. The Supplementary
Benefits Program assists premium assistance beneficiaries
(see section 3.3 of this report) to access the following services:
acupuncture, massage therapy, physiotherapy, chiropractic,
naturopathy, and podiatry (non-surgical services). The program
contributes $23.00 towards the cost of each patient visit to a
maximum of ten visits per patient per annum summed across
the six types of providers.
Physicians enrolled in MSP may choose to be opted-in
or opted-out. Opted-in physicians are physicians who are
enrolled in MSP under section 13 of the MPA and who
elect to bill MSP directly for insured services provided to
MSP beneficiaries. An opted-in physician may not bill a
patient directly for an insured benefit. Opted-out physicians
are physicians who are enrolled in MSP under section 13
of the MPA and who elect to opt out and bill patients
directly for insured benefits. Physicians wishing to opt out
of MSP must give written notice to the Medical Services
Commission (MSC). In this case, patients may apply to MSP
for reimbursement of the fee for insured services rendered.
By law, an opted-out physician may not charge a patient more
for an insured benefit than the prescribed MSP amount.
In 2014–2015, MSP had two opted-out physicians. Based
on reclassification of information and corresponding data,
British Columbia does not track non-participating physicians.
Under the Physician Master Agreement between the government,
the MSC and Doctors of BC, modifications to the Payment
Schedule such as additions, deletions or fee changes are
made by the MSC upon advice from Doctors of BC or the
government. To modify the payment schedule, parties must
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submit proposals to the Doctors of BC Tariff Committee.
On recommendation of the Tariff Committee, interim listings
may be designated by the MSC for new procedures or other
services for a limited period of time while definitive listings
are established.
During fiscal year 2014–2015, 37 physician services were added
as MSP insured benefits to reflect current practice standards
including, for example, the introduction of peritonectomy
with or without chemotherapy.
2.3 Insured Surgical-Dental Services
In certain circumstances, in-patient or out-patient hospitalization
is medically required for the safe and proper completion of
surgical-dental services. In such cases, the surgical-dental
component is covered if the service is listed in the Dental
Payment Schedule and the hospitalization component is
funded by the health authority.
Included as insured surgical-dental procedures are those related to
remedying a disorder of the oral cavity or a functional component
of mastication. Generally this would include oral surgery related
to trauma, orthognathic surgery, medically required extractions,
and surgical treatment of temporomandibular joint dysfunction.
Additions or changes to the list of insured services are managed
by MSP on the advice of the Dental Liaison Committee.
Additions and changes must be approved by the MSC.
Any general dental and/or oral surgeon who is in good standing
with the College of Dental Surgeons, is enrolled in MSP, and
has hospital privileges, may provide insured surgical-dental
services in hospital. There were 214 dentists enrolled with MSP
in 2014–2015 (includes only paediatric dentists, oral surgeons,
dental surgeons, oral medicine, and orthodontist billing
through FFS).
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Medical necessity, as determined by the attending physician,
midwife, nurse practitioner, or oral and maxillofacial surgeon
and hospital, is the criterion for public funding of available
hospital and medical services.
In-patient and out-patient take-home drugs and any
drugs not clinically approved by the hospital are excluded
from coverage.
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Procedures not insured under the Hospital Insurance Act and
its regulations include: services of medical personnel not
employed or contracted by the hospital; treatment for which
WorkSafeBC, the Department of Veterans Affairs or any other
agency is responsible; services or treatment that the Minister
(or a person designated by the Minister) determines, on a review
of the medical evidence, that the beneficiary does not require;
and excluded illnesses or conditions (i.e. in vitro fertilization,
cosmetic service solely for the alteration of appearance; and
reversal of previous sterilization procedures except when
sterilization was originally caused by trauma). Uninsured
hospital services also include: preferred accommodation at
the patient’s request when not medically required; preferred
medical/surgical supplies/devices; televisions, telephones, and
private nursing services; and dental care that could safely be
provided in a dental office including prosthetic and orthodontic
services. Health authorities are required by Ministry policy
to fund medically necessary transfers between acute care
hospitals within British Columbia, but patients are required
to pay a user fee to partially offset costs when an ambulance or
contracted alternative service provider is used for transport in
other situations.
Services not insured under MSP include: those covered by
the Workers’ Compensation Act or by other federal or provincial
legislation; provision of non-implanted prostheses; orthotic
devices; proprietary or patent medicines; any medical
examinations that are not medically required; oral surgery
rendered in a dentist’s office; telephone advice unrelated
to insured visits; reversal of sterilization procedures;
in vitro fertilization; medico-legal services; and most
cosmetic surgeries.
The MPA (section 45) prohibits the sale or issuance of health
insurance by private insurers to patients for services that would
be an insured benefit. Section 17 prohibits persons from being
charged for a benefit or for “materials, consultations, procedures,
and use of an office, clinic or other place or for any other matters
that relate to the rendering of a benefit.”
The Ministry responds to complaints made by patients and
takes appropriate actions to correct situations identified to the
Ministry. The MSC determines which services are benefits
and has the authority to de-insure insured services. Proposals
to de-insure services must be made to the MSC. Consultation
may take place through a sub-committee of the MSC and
usually includes a review by Doctors of BC’s Tariff Committee.
In 2013-2014, nine fee items from the Section of Laboratory
Medicine were removed from the Fee Schedule; each of the
items was related to drugs of abuse testing and was found to
be redundant or obsolete.
CHAPTER 3: BRITISH COLUMBIA
3.0UNIVERSALITY
3.1Eligibility
Section 7 of the Medicare Protection Act (MPA) defines the
eligibility and enrolment of beneficiaries for insured services.
Under the MPA, Part 2 of the Medical and Health Care
Services Regulation details residency requirements. A person
must be a resident of British Columbia to qualify for provincial
healthcare benefits.
3.2 Other Categories of Individuals
Some holders of Minister’s Permits, Temporary Resident
Permits, study permits, work permits and applicants for
permanent resident status who are the spouse or child of
an eligible resident may be eligible for benefits when deemed
to be residents under the MPA and section 2 of the Medical
and Health Care Services Regulation.
3.3Premiums
Section 1 of the MPA defines a resident as a person who:
The enabling legislation is:
■■ is a citizen of Canada or is lawfully admitted to Canada
■■ Medicare Protection Act, Part 2 — Beneficiaries section 8; and
for permanent residence;
■■ makes his or her home in British Columbia, and is physically
present in British Columbia for at least six months in a
calendar year, or for a prescribed shorter period of time; and
■■ is deemed under the regulations to be a resident
(does not include a tourist or visitor to British Columbia).
Certain other individuals, such as some holders of
permits issued under the federal Immigration and Refugee
Protection Act are deemed to be residents (see section 3.2 of
this report), but this does not include a tourist or visitor to
British Columbia.
In 2014–2015, the Medical and Health Care Services
Regulation was amended to clarify the terms upon which a
resident of British Columbia may be absent from the province
due to vacation or work and remain a beneficiary who
qualifies for healthcare benefits.
New residents or persons re-establishing residence in
British Columbia must be physically present in British Columbia
for at least six months prior to being absent for more than
six months. If absences exceed six months prior to the individual
being physically present for at least six months, residence is not
established and medical coverage is canceled as of the initial
enrolment date.
All residents are entitled to hospital and medical care
insurance coverage. Those residents who are members of the
Canadian Forces and those serving a term of imprisonment
in a penitentiary as defined in the Penitentiary Act, are
eligible for federally funded health insurance. The Medical
Services Plan (MSP) provides first-day coverage to discharged
members of the Canadian Forces and to those returning from
an overseas tour of duty, as well as to released inmates of
federal penitentiaries.
■■ Medical and Health Care Services Regulation,
Part 3 — Premiums.
Enrolment in MSP is mandatory and payment of premiums
is ordinarily a requirement for coverage. However, failure to
pay premiums is not a barrier to coverage for those who meet
the basic enrolment eligibility criteria. Monthly premiums
for MSP since January 1, 2015, are $72.00 for one person,
$130.50 for a family of two, and $144.00 for a family of
three or more.
MSP has two programs that offer assistance with the
payment of premiums based on financial need. Regular
premium assistance has five levels of assistance and is
based on a person’s net income for the preceding tax year,
combined with that of the person’s spouse, if applicable,
less MSP deductions. In 2014–2015, amendments to Part 3
of the Medical and Health Care Services Regulation
changed provisions specifying the calculation of income
for determining eligibility for premium assistance. New
provisions address the application of premium assistance for
beneficiaries “in care” at institutions designated as hospitals
or nursing homes licensed as private hospitals, and those
in receipt of long-term care at a licensed community care
facility, and for beneficiaries whose spouse is in care.
A short term, 100 percent subsidy is offered under the
temporary premium assistance program based on current,
unexpected financial hardship. Premium assistance is available
only to beneficiaries who, for the last 12 consecutive months,
have resided in Canada and are either a Canadian citizen or a
holder of permanent resident (landed immigrant) status under
the federal Immigration and Refugee Protection Act.
The number of residents registered with MSP as of
March 31, 2015 was 4,672,899.
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4.0PORTABILITY
4.1 Minimum Waiting Period
New residents or persons re-establishing residence in
British Columbia are eligible for coverage after completing
a waiting period that normally consists of the balance of the
month residence is established plus two additional months.
For example, if an eligible person arrives during the month of
July, coverage is available October 1. If absences from Canada
exceed a total of 30 days during the waiting period, eligibility
for coverage may be affected. New residents from other parts
of Canada are advised to maintain coverage with their former
medical plan during the waiting period.
4.2 Coverage During Temporary Absences
in Canada
Sections 3, 4 and 5 of the Medical and Health Care Services
Regulation define portability provisions for persons temporarily
absent from British Columbia with regard to insured services.
Residents who spend part of every year outside British Columbia
must be physically present in Canada at least six months in a
calendar year and continue to maintain their home in British
Columbia in order to retain coverage. As of January 1, 2013,
longer term vacationers who are deemed residents may qualify
for a total absence of up to seven months per calendar year for
vacation purposes only, provided they continue to maintain their
home in British Columbia.
Individuals leaving the province temporarily on extended
vacations, or for temporary employment, may be eligible
to retain their medical coverage for up to 24 consecutive
months provided that they are physically present in BC
for six of the 12 months immediately preceding departure.
Approval is limited to once in five years for absences exceeding
six months in a calendar year. When a beneficiary stays outside
British Columbia longer than the approved period, they will
be required to fulfill a waiting period upon re-establishing
residence in the province before coverage can be renewed.
Students attending a recognized school in another province
or territory on a full-time basis are entitled to coverage for
the duration of their studies, provided that they return to BC
permanently by the last day of the month following the month
in which their studies end.
According to inter-provincial/territorial reciprocal billing
arrangements, physicians, except in Quebec, bill their own
medical plans directly for services rendered to British Columbia
residents who are eligible for the Medical Services Plan (MSP),
upon presentation of a valid CareCard or BC Services Card.
British Columbia then reimburses the province or territory
at the rate of the fee schedule in the province or territory in
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which services were rendered. For in-patient hospital care,
services are paid at the ward rate approved for each hospital by
the Assistant Deputy Ministers Policy Advisory Committee.
For out-patient services, the payment is at the inter-provincial/
territorial reciprocal billing rate. Payment for these services,
except for excluded services that are billed to the patient,
is handled through inter-provincial/territorial reciprocal
billing procedures.
Quebec does not participate in reciprocal billing agreements
for physician services. As a result, claims for services provided
to British Columbia beneficiaries by Quebec physicians must
be handled individually. When travelling in Quebec (or outside
of Canada) the beneficiary is usually required to pay for medical
services and seek reimbursement later from MSP.
British Columbia pays host provincial rates for insured services
according to rates established by the Interprovincial Health
Insurance Agreements Coordinating Committee.
4.3 Coverage During Temporary Absences
Outside Canada
The legislation that defines portability of health insurance
during temporary absences outside Canada is stated in the
Hospital Insurance Act, section 24; the Hospital Insurance
Act Regulations, Division 6; the Medicare Protection Act,
section 51; and the Medical and Health Care Service
Regulation, sections 3, 4, and 5.
Residents who leave British Columbia temporarily to attend school
or university are eligible for MSP coverage for the duration of their
studies provided they were physically present in Canada for six of
the 12 months immediately preceding departure, and are in fulltime attendance at a recognized educational facility. Beneficiaries
who have been studying outside British Columbia must return
to the province by the end of the month following the month in
which studies are completed. Any student who will not return to
British Columbia within that timeframe should contact MSP.
Residents who spend part of every year outside British Columbia
must be physically present in Canada at least six months
in a calendar year and continue to maintain their home
in British Columbia in order to retain coverage. As of
January 1, 2013, longer term vacationers who are deemed
residents may qualify for a total absence of up to seven months
per calendar year for vacation purposes.
In some circumstances, while temporarily outside the province for
work or vacation, an individual may be deemed an eligible resident
during an ‘extended absence’ of up to 24 consecutive months
once in a five-year period. To qualify, he or she must continue to
maintain their home in British Columbia, be physically present in
Canada for six of the 12 months immediately preceding departure
and have not been granted an extended absence in the previous five
calendar years. In addition, they must not have taken advantage of
CHAPTER 3: BRITISH COLUMBIA
the additional one month absence available to vacationers during
the year the extended absence begins, or during the calendar year
prior to the start of the extended absence. In certain situations,
if a person’s employment requires them to routinely travel outside
of British Columbia for more than six months per calendar year,
they can apply to the Medical Services Commission (MSC) for
approval to maintain their eligibility.
British Columbia residents who are temporarily absent from
British Columbia and cannot return due to extenuating health
circumstances may be deemed residents for up to an additional
12 months if they are visiting in Canada or abroad. This also
applies to the person’s spouse and children provided they are
with the person and they are also residents or deemed residents.
British Columbia residents who are eligible for coverage
while temporarily absent from British Columbia may receive
reimbursement from MSP for out-of-country medical expenses.
MSP provides coverage for out-of-country emergency physician
services up to the B.C. physician fee rates. Reimbursement
for out-of-country emergency hospital services is limited to
a maximum benefit of $75.00 per day. Any excess cost is the
responsibility of the beneficiary. All reimbursement is made
in Canadian dollars.
4.4 Prior Approval Requirement
No prior approval is required for medically required procedures
that are covered under interprovincial reciprocal agreements with
other provinces. Prior approval from the MSC is required for
procedures that are excluded under the reciprocal agreements.
The physician services excluded under the Interprovincial
Agreements for the Reciprocal Processing of Out-of-Province
Medical Claims are: surgery for alteration of appearance
(cosmetic surgery); gender reassignment surgery; surgery
for reversal of sterilization; routine periodic health
examinations including routine eye examinations; in vitro
fertilization, artificial insemination; acupuncture, acupressure,
transcutaneous electro-nerve stimulation, moxibustion,
biofeedback, hypnotherapy; services to persons covered by
other agencies (e.g., Canadian Armed Forces, Workers’
Compensation Board, Department of Veterans Affairs,
Correctional Services of Canada); services requested by a
third party; team conferences; genetic screening and other
genetic investigation, including DNA probes; procedures still
in the experimental/developmental phase; and anaesthetic
services and surgical assistant services associated with all of
the foregoing.
The services on this list may or may not be reimbursed by
the home province. The patient should make inquiries of
that home province either before receiving treatment by a
British Columbia physician or after direct payment to the
British Columbia physician. Some treatments (e.g., treatment
services in not-for-profit residential facilities) may require the
recommendation of the Ministry of Health.
All non-emergency procedures performed outside Canada
require approval from the MSC before the procedure.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
Beneficiaries in British Columbia, as defined in section 1 of
the Medicare Protection Act (MPA), are eligible for all insured
hospital and medical care services as required. To ensure equal
access to all, regardless of income, the MPA, sections 17 and
18, prohibits extra-billing by enrolled practitioners.
Access to insured services continues to be enhanced:
■■ The Alternative Payments Program funds regional health
authorities to contract with or hire general practitioners
(GPs) and/or specialists in order to deliver insured
clinical services.
■■ The Full-Service Family Practice Incentive Program
continues to be expanded as the Ministry of Health
(the Ministry) and physicians continue to work together
to develop incentives aimed at helping to support and
sustain full-service family practice.
■■ The Ministry provides funding through the Medical
On-Call Availability Program to health authorities
to enable them to contract with groups of physicians
to provide “on-call” coverage necessary for hospitals
to deliver emergency healthcare services to unassigned
patients in a reliable, effective, and efficient manner.
■■ The Ministry continued and implemented several
programs under the 2012 Rural Practice Subsidiary
Agreement, which were continued in the Physician
Master Agreement (PMA) to enhance the availability
and stability of physician services in smaller urban,
rural, and remote areas of British Columbia.
An outline of these programs can be obtained at:
www.health.gov.bc.ca/pcb/rural.html
Infrastructure and Capital Planning
British Columbia continues to make strategic investments
in health sector capital infrastructure. The Ministry invests
annually to renew and extend the asset life of existing health
facilities, medical and diagnostic equipment, and information
management technology at numerous health facilities across
British Columbia. The Ministry has developed a ten-year
capital plan to ensure health infrastructure is maintained
and renewed within expected asset lifecycle timelines.
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CHAPTER 3: BRITISH COLUMBIA
5.2 Physician Compensation
Compensation Methods for Physicians and Dentists
The PMA is a formal agreement signed by the Government
of British Columbia, BC Medical Association (the Doctors
of BC), and the Medical Services Commission (MSC). In
December 2014, doctors in British Columbia voted in favour of
a new agreement with government. The new five-year agreement
(term April 1, 2014 to March 31, 2019) supports ongoing efforts
to recruit and retain physicians while also improving access to
specialists and care in rural and remote communities.
Payment for medical services delivered in the province is made
through MSP to individual physicians, based on submitted
claims, and through the Alternative Payment Program to
health authorities for physician time spent providing services
to patients. The government funds health authorities to enter
into alternative payment arrangements with other physicians;
it does not pay physicians directly. In British Columbia, MSP
only pays for medically required dental services and medically
required dental surgical services performed in a hospital.
The PMA gives the Doctors of BC exclusive right to represent
the interests of all physicians who receive payment for the
medical services they provide to persons insured through MSP.
The PMA establishes mechanisms which promote enhanced
collaboration and accountabilities between the province and
Doctors of BC through various joint committees. It also
provides a formal conflict management process at both the local
and provincial levels and language limiting physician service
withdrawals. The role of health authorities in the planning and
delivery of healthcare services are reinforced in the PMA.
The PMA establishes the compensation and benefit structure
for physicians who provide publicly funded medical services
whether on fee-for-service or alternate funding methods
(service contracts, salaries, and sessional arrangements).
Through the PMA, the province also provides targeted
financial support for areas such as: rural physician incentive
programs; access to specialist services; supporting full service
family practices; and shared care models involving GPs,
specialists, and other healthcare professions.
Physicians are licensed under the Health Professions Act, with
their Payment Schedule established under section 26 of the
MPA. The agreement provides processes for monitoring and
managing the funding established by the MSC under section
25 of the MPA for insured medical services provided by
physicians on a fee-for-service basis. Mechanisms for revisions
to the Payment Schedule and for the payment of physicians
are detailed in the PMA.
Dentists are licensed under the Health Professions Act.
The province and the British Columbia Dental Association
(BCDA) have entered into a Dentistry Master Agreement for
the period April 1, 2014 to March 31, 2019 that covers the
following services: dental surgery; oral surgery; orthodontic
services; oral medicine; pediatric dental services; and dental
technical procedures. Both the province and the BCDA meet
through a Dentistry Liaison Committee for the duration of
the agreement.
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5.3 Payments to Hospitals
Funding for insured hospital services are included within
annual funding allocations to health authorities, as well as
specifically targeted funding from time to time. This funding
allocation is used to fund the full range of necessary health
services for the population of the region (or for specific
provincial services, for the population of British Columbia),
including the provision of hospital services. Annual funding
allocations to health authorities are determined as part of the
Ministry’s annual budget process in consultation with the
Ministry of Finance and Treasury Board. The final funding
amount is conveyed to health authorities by means of an annual
funding letter.
The Hospital Insurance Act and its related regulations and the
Health Authorities Act govern payments made by government
to health authorities. These statutes establish the authority of
the Minister of Health to make payments to regional health
authorities, the Provincial Health Services Authority and the
Nisga’a Nation; and specifies in broad terms what services are
insured when provided within a hospital and in delivering
regional healthcare services.
The British Columbia Tripartite Framework Agreement
on First Nation Health Governance and other negotiated
agreements, provide the basis for the Ministry of Health
to provide funding to the First Nations Health Authority.
The Ministry does not specifically fund hospitals directly;
instead health authorities are funded and provide operating
budgets to hospitals within their control to deliver specified
services. The exception to this is when funding provided to
health authorities (again not directly to hospitals) is targeted
for specific priority projects (e.g., reduction in wait times for
specific procedures). Since it is specifically targeted, it must
be reported on separately.
CHAPTER 3: BRITISH COLUMBIA
Incremental funding is allocated to health authorities using
the Ministry’s Population Needs-Based Funding Formula and
other funding allocation methodologies (e.g., to reflect targeted
funding allocations directed to specific health authorities). The
annual funding allocation to health authorities does not include
funding for programs directly operated by the Ministry, such as
payments to physicians through the Medical Services Plan and
payments for prescription drugs covered under PharmaCare.
In 2014–2015, the Ministry continued to examine alternative
funding methodologies including the use of pay-for-performance
and activity-based funding.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
The accountability mechanisms associated with government
funding for hospitals is part of several comprehensive documents
which set expectations for health authorities. These are the
annual funding letter, annual service plans, and annual
Government Letters of Expectations. Taken together, these
documents convey the Ministry’s broad expectations for health
authorities and explain how performance will be monitored in
relation to these expectations.
■■ Budget and Fiscal Plan 2014–2015 to 2016–2017, available at:
Funding provided by the federal government through the
Canada Health Transfer is recognized and reported by the
Government of British Columbia through various government
websites and provincial government documents. In 2014–2015,
these documents included:
■■ Estimates, Fiscal Year Ending March 31, 2015, available at:
http://bcbudget.gov.bc.ca/2014/estimates/2014_Estimates.pdf
http://bcbudget.gov.bc.ca/2014/bfp/2014_budget_and_
fiscal_plan.pdf
■■ Public Accounts 2014–2015, available at:
http://www.fin.gov.bc.ca/ocg/pa/14_15/Public%20
Accounts%2014-15.pdf
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CHAPTER 3: BRITISH COLUMBIA
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4,521,503
4,565,864
4,594,940
4,625,653
4,672,899
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
119
120
120
120
121
not available
not available
not available
not available
not available
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4. Number of private for-profit facilities
providing insured health services (#).
not available
not available
not available
not available
not available
5. Payments to private for-profit facilities
for insured health services ($).
not available
not available
not available
not available
not available
2. Number (#).1
3. Payments for insured health services ($). 2
Private For-Profit Facilities
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
5,909
6,551
6,886
7,038
6,053
67,078,612
69,785,313
68,904,638
73,641,805
64,421,846
78,075
86,544
97,088
93,382
81,547
21,830,298
25,327,347
28,643,797
29,362,893
28,402,123
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
2,469
2,961
4,091
2,689
2,271
4,452,628
4,152,060
4,520,778
4,747,415
3,128,917
1,940
2,468
2,915
2,709
3,713
999,733
1,301,179
1,646,810
2,098,735
1,599,213
1. As per the guidelines, the number of public facilities in this table excludes psychiatric hospitals and extended care facilities.
2. BC Ministry of Health Funding to Health Authorities for the provision of the full range of regionally delivered services are as follows: $9.2 billion in 2010–2011,
$9.7 billion in 2011–2012, $10.1 billion in 2012–2013, $10.5 billion in 2013-2014, and $10.8 billion in 2014–2015.
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CHAPTER 3: BRITISH COLUMBIA
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
9,417
9,628
9,947
10,119
10,411
5
5
4
2
2
16.Number of not participating physicians (#).
not available
not available
not available
not available
not available
17. Total payments for services provided
by physicians paid through all payment
methods ($).
not available
not available
not available
not available
not available
2,541,874,909
2,619,943,719
2,656,938,267
2,758,295,568
2,808,025,394
14.Number of participating physicians (#). 3
15.Number of opted-out physicians (#).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
625,981
653,387
628,705
681,401
704,663
30,698,752
32,453,109
32,502,933
33,860,748
37,002,462
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
82,247
91,026
83,050
76,084
73,551
4,240,090
4,869,497
4,340,034
4,148,174
4,091,804
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
236
218
217
212
214
51,036
52,047
50,813
54,120
54,053
7,991,262
8,130,009
7,903,742
8,456,773
8,417,735
3. The number of participating physicians in item 14 is for physicians who received payments through fee-for-service.
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YUKON
INTRODUCTION
The Yukon Health Care System is committed to ensuring that
residents of the Yukon acquire the skills to live responsible,
healthy and independent lives. The Minister of Health and
Social Services is responsible for delivering all insured health
care services with service delivery administered centrally
by the Department of Health and Social Services (DHSS).
The overall objective of the DHSS is to ensure access to, and
portability of, insured physician and hospital services according
to the provisions of the Health Care Insurance Plan Act and the
Hospital Insurance Services Act.
Additionally, extended health benefits provided to eligible
Yukon residents include the Travel for Medical Treatment
Program; the Children’s Drug and Optical Program; the
Chronic Disease and Disability Benefits Program; and the
Pharmacare and Extended Benefits Programs. Other health
service programs administered by DHSS include Community
Health; Community Nursing; Continuing Care; and Mental
Health Services. Currently, most communities in Yukon
contain Community Health Centres, where residents have
access to a team of health care professionals with diverse skills.
The Yukon Hospital Corporation operates the three hospitals
in the territory: Whitehorse General Hospital, Watson
Lake Community Hospital and Dawson City Community
Hospital. In January 2015, a temporary facility at the
Whitehorse General Hospital (WGH) opened which houses
Canada’s first magnetic resonance imaging (MRI) program
north of 60. In addition, in 2014–2015 construction was started
at WGH to expand the Emergency Department and provide
expansion of the Radiology Department along with providing
a permanent location for the MRI program.
The Yukon Government continues to utilize teleradiology and
telehealth services to improve health care services for Yukoners
living in more rural communities. Further, Nurse Practitioner
(NP) legislation that was enacted in December 2012, has
allowed the Yukon Registered Nurses Association to license
five NPs in Yukon to expand health care options for patients,
and improve the quality and access of collaborative primary
care. Currently there are four NPs delivering services
in Whitehorse.
In 2014–2015, Insured Health and Hearing Services (IHS)
contracted with a Nurse Practitioner to open a Women’s
Midlife Health Clinic and a Reproductive Health Clinic.
IHS also hired a Nurse Practitioner to work at the Referred
Care Clinic in Whitehorse in September 2014.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
The Government of Yukon delivers insured health benefits
according to the Yukon Health Care Insurance Plan (YHCIP)
and the Yukon Hospital Insurance Services Plan (YHISP).
Both the YHCIP and YHISP are administered by the Director,
Insured Health and Hearing Services. This position is a joint
appointment by the Minister of Health and Social Services and
the Commissioner of the Yukon Territory.
The Health Care Insurance Plan Act, section 3(2) and section 4,
establishes the public authority to operate the health care plan.
There were no amendments made to these sections of the Act
in 2014–2015.
The Hospital Insurance Services Act, section 3(1) and section 5,
establishes the public authority to operate the hospital care
plan. There were no amendments made to these sections of
the Act in 2014–2015.
Subject to the Health Care Insurance Plan Act (section 5), the
Hospital Insurance Services Act (section 6) and the regulations,
it is the responsibility of the Director, Insured Health and
Hearing Services to:
■■ administer both plans;
■■ determine eligibility for insured health services;
■■ establish advisory committees and appoint individuals
to advise or assist in the operation of the plans;
■■ determine the amounts payable for insured health services
outside the Yukon;
■■ conduct surveys and research programs, and obtain statistics
for such purposes;
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■■ appoint inspectors and auditors to examine and obtain
information from medical records, reports, and accounts; and
■■ perform any other functions and discharge any other duties
assigned by the Minister of Health and Social Services
under the Act.
Specific to the Hospital Insurance Services Act, the Director,
Insured Health and Hearing Services has the responsibility to:
■■ enter into agreements on behalf of the Government of
Yukon with hospitals in or outside of Yukon, or with the
Government of Canada or any province or an appropriate
agency thereof, for the provision of insured services to
insured persons;
■■ prescribe the forms and records necessary to carry out the
provisions of the Act; and
■■ perform any other functions and discharge any other duties
assigned to the administrator by the Regulations.
There were no amendments to either Act in 2014–2015.
1.2 Reporting Relationship
The Department of Health and Social Services is accountable
to the Legislative Assembly and the Government of Yukon
through the Minister.
Section 6 of the Health Care Insurance Plan Act and section 7
of the Hospital Insurance Services Act require that the Director,
Insured Health and Hearing Services make an annual report
to the Minister of Health and Social Services respecting the
administration of the two health insurance plans. A Statement
of Revenue and Expenditures is tabled in the legislature and
is subject to discussion at that level. The Statement of Revenue
and Expenditures will be tabled in the fall 2015 sitting of the
Yukon legislature.
1.3 Audit of Accounts
The Health Care Insurance Plan and the Hospital Insurance
Services Plan are subject to audit by the Office of the Auditor
General of Canada. The Auditor General of Canada is the
Auditor of the Government of Yukon in accordance with
section 34 of the Yukon Act (Canada). The Auditor General is
required to conduct an annual audit of the transactions and
consolidated financial statements of the Government of Yukon.
Further, the Auditor General of Canada is to report to the
Yukon Legislative Assembly any matter falling within the scope
of the audit that, in his or her opinion, should be reported to
the Assembly.
In 2013, the Office of the Auditor General of Canada released
the 2013 Report of the Auditor General of Canada, Capital
Projects — Yukon Hospital Corporation. There were no reports
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related to the Department of Health and Social Services
released in 2014–2015.
Further, section 13(2) of the Hospital Act requires the Yukon
Hospital Corporation to submit a report of their operations
for that fiscal year to the Minister within six months after the
end of each fiscal year. The report is to include the financial
statements of the Corporation and the Auditor’s report.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
The Hospital Insurance Services Act, sections 3, 4, 5, 6 and 9,
establish authority to provide insured hospital services to
insured residents. The Yukon Hospital Insurance Services
Ordinance was first passed in 1960 and came into effect
April 9, 1960. No amendments were made to the Act
in 2014–2015.
Adopted on December 7, 1989, the Hospital Act establishes
the responsibility of the legislature and the government
to ensure “compliance with appropriate methods of
operation and standards of facilities and care.” Adopted
on November 11, 1994, the annexed Hospital Standards
Regulation sets out the conditions under which all hospitals
in the territory are to operate. Section 4(1) provides for the
Ministerial appointment of one or more investigators to
report on the management and administration of a hospital.
Section 4(2) requires that the hospital’s Board of Trustees
establish and maintain a quality assurance program.
In April 1997, the Yukon Government assumed responsibility
for operating health centres in rural Yukon communities from
the federal government. These facilities operate in compliance
with the adopted Medical Services Branch Scope of Practice for
Community Health Nurses, Nursing Station Facility, Health
Centre Treatment Facility and the Community Health Nurse
Scope of Practice. The General Duty Nurse Scope of Practice
was completed and implemented in February 2002.
In 2014–2015, insured in-patient and out-patient hospital
services were delivered in 14 facilities throughout the territory.
These facilities include Whitehorse General Hospital, Watson
Lake Community Hospital, Dawson City Community
Hospital and 11 primary health care centres.
The Yukon Hospital Corporation completed their accreditation
process in May 2014 as part of a four-year cycle through
Accreditation Canada. Whitehorse General Hospital and
Watson Lake Community Hospital took part in this process,
while Dawson City Community Hospital will take part in the
next process in 2018.
CHAPTER 3: YUKON
Pursuant to the Hospital Insurance Services Regulations,
section 2(e) and (f), services provided in an approved hospital
are insured. Section 2(e) defines in-patient insured services
as all of the following services to in-patients, namely:
accommodation and meals at the standard or public ward
level; necessary nursing service; laboratory, radiological and
other diagnostic procedures together with the necessary
interpretations for the purpose of maintaining health,
preventing disease and assisting in the diagnosis and treatment
of an injury, illness or disability; drugs, biologicals and related
preparations as provided in Schedule B of the Regulations,
when administered in the hospital; use of operating room, case
room and anaesthetic facilities, including necessary equipment
and supplies; routine surgical supplies; use of radiotherapy
facilities where available; use of physiotherapy facilities
where available; and services rendered by persons who receive
remuneration therefor from the hospital.
Section 2(f) of the regulations defines “out-patient insured
services” as all of the following services to out-patients, when
used for emergency diagnosis or treatment within 24 hours
of an accident (period may be extended by the Administrator,
provided the service could not be obtained within 24 hours of
the accident): necessary nursing service; laboratory, radiological
and other procedures, together with the necessary interpretations
for the purpose of assisting in the diagnosis and treatment of an
injury; drugs, biologicals and related preparations as provided in
Schedule B, when administered in a hospital; use of operating
room and anaesthetic facilities, including necessary equipment
and supplies; routine surgical supplies; services rendered by
persons who receive remuneration therefor from the hospital;
use of radiotherapy facilities where available; and use of
physiotherapy facilities where available.
Pursuant to the Hospital Insurance Services Regulations,
all in-patient and out-patient services provided in an approved
hospital, by hospital employees, are insured services.
Standard nursing care, pharmaceuticals, supplies, diagnostic
and operating services are provided. Any new programs
or enhancements with significant funding implications or
reductions to services or programs require the prior approval
of the Minister, Health and Social Services. This process
is managed by the Director, Insured Health and Hearing
Services. Public representation regarding changes in service
levels is made through membership on the hospital board.
Yukon remains committed to the administration of the Weight
Wise program in Whitehorse. In previous years, clients were
sent to Alberta to participate in the program. With the help
of Alberta Health Services, a local physician and a local
registered nurse have been trained in delivering the program
in-territory. The first intake of clients began in the fall of 2010.
The Whitehorse General Hospital opened the first MRI in
northern Canada on January 13, 2015. Whitehorse General
Hospital also began construction on a permanent location for
the MRI along with an expansion of the Emergency Room
Department in 2014–2015.
These measures will help reduce Yukon’s reliance on out-ofterritory services.
2.2 Insured Physician Services
Insured physician services in Yukon are defined as medically
required services rendered by a medical practitioner. Sections 1
to 8 of the Health Care Insurance Plan Act and sections 2, 3, 7, 10
and 13 of the Health Care Insurance Plan Regulations provide
for insured physician services. No amendments were made to
the Act in 2014–2015.
The Yukon Health Care Insurance Plan covers physicians
providing medically required services. In order to participate
in the Yukon Health Care Insurance Plan, physicians must:
■■ register for licensure pursuant to the Health Professions Act; and
■■ maintain licensure, pursuant to the Health Professions Act.
The number of resident physicians participating in the Yukon
Health Care Insurance Plan in 2014–2015 was 70, along with
36 locums and 45 visiting specialists.
Section 7 of the Yukon Health Care Insurance Plan Regulations
covers payment for medical services. Subsection 4 allows
physicians to make arrangements for payment for insured
services on a basis other than fee-for-service. Notice in writing
of this election must be submitted to the Director, Insured
Health and Hearing Services. In 2014–2015, there were
physicians both on fee-for-service and alternate payment
arrangements for remuneration.
The process used to add a new fee to the Payment Schedule
for Yukon is administered through a committee structure.
This process requires physicians to submit requests in
writing to the Yukon Health Care Insurance Plan, Yukon
Medical Association Liaison Committee. Following review
by this committee, a decision is made to include or exclude
the service. The relevant costs or fees are normally set in
accordance with similar costs or fees in other jurisdictions.
Once a fee-for-service value has been determined, notification
of the service and the applicable fee is provided to all Yukon
physicians. Public consultation is not required.
Alternatively, new fees can be implemented as a result of the fee
negotiation process between the Yukon Medical Association
and the Department of Health and Social Services. The
Director, Insured Health and Hearing Services manages this
process and no public consultation is required.
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CHAPTER 3: YUKON
2.3 Insured Surgical-Dental Services
Dentists providing insured surgical-dental services under the
health care insurance plan of Yukon must be licensed pursuant
to the Dental Professions Act and are given billing numbers
to bill the Yukon Health Care Insurance Plan for providing
insured dental services. The Plan is also billed directly for
services provided outside the territory.
Insured dental services are limited to those surgical-dental
procedures listed in Schedule B of the Health Care Insurance
Plan Regulations. The procedures must be performed in
a hospital.
The addition or deletion of new surgical-dental services to the
list of insured services requires amendment by Order-in-Council
to Schedule B of the Health Care Insurance Plan Regulations.
Coverage decisions are made on the basis of whether or not the
service must be provided in hospital under general anaesthesia.
The Director, Insured Health and Hearing Services administers
this process.
bill by service item. Billable services include but are not limited
to: completion of employment forms; medical-legal reports;
transferring records; third-party examinations; some elective
services; and telephone prescriptions, advice or counseling.
Payment does not affect patient access to services because not
all physicians or clinics bill for these services and other agencies
or employers may cover the cost.
Uninsured dental services include procedures considered
restorative and procedures that are not performed in a hospital
under general anesthesia.
All Yukon residents have equal access to services. Third parties,
such as private insurers or the Worker’s Compensation Health
and Safety Board, do not receive priority access to services
through additional payment. The purchase of non-insured
services, such as fiberglass casts, does not delay or prevent
access to insured services at any time. Insured persons are given
treatment options at the time of service.
There were no new insured surgical-dental services added in
2014–2015.
Yukon has no formal process to monitor compliance; however,
feedback from physicians, hospital administrators, medical
professionals and staff allows the Director, Insured Health and
Hearing Services to monitor usage and service concerns.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
The process used to de-insure services covered by the Yukon
Health Insurance Plan is as follows:
Only services prescribed by and rendered in accordance with
the Health Care Insurance Plan Act and Regulations and the
Hospital Insurance Services Act and Regulations are insured.
All other services are uninsured.
Uninsured hospital services include: non-resident hospital
stays; special or private nurses requested by the patient or
family; additional charges for preferred accommodation unless
prescribed by a physician; crutches and other such appliances;
nursing home charges; televisions; telephones; and drugs and
biologicals following discharge. (These services are not provided
by the hospital).
Section 3 of the Yukon Health Care Insurance Plan Regulations
contains a list of services that are prescribed as non-insured.
Uninsured physician services include: advice by telephone;
medical-legal services; testimony in court; preparation of
records, reports, certificates and communications; services or
examinations required by a third party; services, examinations
or reports for reasons of attending university or camp;
examination or immunization for the purpose of travel,
employment or emigration; cosmetic services; services not
medically required; giving or writing prescriptions; the supply
of drugs; dental care except procedures listed in Schedule B;
and experimental procedures.
Physicians in Yukon may bill patients directly for non-insured
services. Block fees are not used at this time; however, some do
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Physician services — the Yukon Health Care Insurance
Plan, Yukon Medical Association Fee Liaison Committee is
responsible for reviewing changes to the Payment Schedule
for Yukon including decisions to de-insure certain services.
In consultation with the Yukon Medical Advisor, decisions
to de-insure services are based on medical evidence that
indicates the service is not medically necessary, is ineffective
or a potential risk to the patient’s health. Once a decision has
been made to de-insure a service, all physicians are notified in
writing. The Director, Insured Health and Hearing Services,
manages this process. No services were removed in 2014–2015.
Hospital services — an amendment by Order-in-Council
to sections 2(e) and 2(f) of the Yukon Hospital Insurance
Services Regulations would be required. As of March 31, 2015,
no insured in-patient or out-patient hospital services, as
provided for in the Regulations, have been de-insured. The
Director, Insured Health and Hearing Services is responsible
for managing this process in conjunction with the Yukon
Hospital Corporation.
Surgical-dental services — an amendment by Order-inCouncil to Schedule B of the Health Care Insurance Plan
Regulations is required. A service could be de-insured if
determined not medically necessary or is no longer required
to be carried out in a hospital under general anaesthesia.
The Director, Insured Health and Hearing Services manages
this process. No surgical-dental services were de-insured
in 2014–2015.
CHAPTER 3: YUKON
3.0UNIVERSALITY
3.2 Other Categories of Individuals
3.1Eligibility
The Yukon Health Care Insurance Plan provides health care
coverage for other categories of individuals, as follows:
Eligibility requirements for insured health services are set
out in the Health Care Insurance Plan Act and Regulations,
sections 2 and 4, and the Hospital Insurance Services Act and
Regulations, sections 2 and 4. There were no changes to the
legislation in 2014–2015.
Subject to the provisions of these acts and regulations, every
Yukon resident is eligible for and entitled to insured health
services on uniform terms and conditions. The term “resident”
is defined using the wording of the Canada Health Act and
means a person lawfully entitled to be or to remain in Canada,
who makes his or her home and is ordinarily present in Yukon,
but does not include a tourist, transient or visitor. Pursuant
to section 4(1) of the Yukon Health Care Insurance Plan
Regulations and the Yukon Hospital Insurance Services
Regulations, an insured person is eligible for and entitled to
insured services after midnight on the last day of the second
month following the month of arrival to the Territory. All
persons returning to or establishing residency in Yukon are
required to complete this waiting period. The only exception
is for children adopted by insured persons, and for newborns.
The following persons are not eligible for coverage in Yukon:
■■ persons entitled to coverage from their home province
or territory (e.g., students and workers covered under
temporary absence provisions);
■■ visitors to Yukon;
■■ refugee claimants;
■■ convention refugees;
■■ inmates in federal penitentiaries;
■■ study permit holders, unless they are a child and they are
listed as the dependent of a person who holds a one year
work permit; and
■■ employment authorizations of less than one year.
The above persons may become eligible for coverage if they
meet one or more of the following conditions:
■■ establish residency in Yukon;
■■ become a permanent resident; or
■■ for inmates at the Whitehorse Correctional Centre, the day
following discharge or release if stationed in or a resident
in Yukon.
The number of registrants in the Yukon Health Care Insurance
Plan as of March 31, 2015 was 38,261.
Returning Canadians — waiting period is applied
Permanent Residents — waiting period is applied
Minister’s Permit — waiting period is applied, if authorized
Foreign Workers — waiting period is applied, if holding
Employment Authorization
Clergy — waiting period is applied, if holding Employment
Authorization
Employment Authorizations must be in excess of 12 months.
4.0PORTABILITY
4.1 Minimum Waiting Period
Where applicable, the eligibility of all persons is administered
in accordance with the Interprovincial Agreement on Eligibility
and Portability. Under section 4(1) of both regulations, “an
insured person is eligible for and entitled to insured services
after midnight on the last day of the second month following
the month of arrival to the Territory.” All persons entitled to
coverage are required to complete the minimum waiting period
with the exception of children adopted by insured persons
(see section 3.1), and newborns.
4.2 Coverage During Temporary Absences
in Canada
The provisions relating to portability of health care insurance
during temporary absences outside Yukon, but within Canada,
are defined in sections 5, 6, 7 and 10 of the Yukon Health Care
Insurance Plan Regulations and sections 6, 7(1), 7(2) and 9 of
the Yukon Hospital Insurance Services Regulations.
The Regulations state that, “where an insured person is absent
from the Territory and intends to return, he/she is entitled
to insured services during a period of 12 months continuous
absence.” Persons leaving Yukon for a period exceeding three
months are advised to contact Yukon Insured Health Services
and complete a Temporary Absence form. Failure to do so may
result in cancellation of coverage.
Students attending educational institutions full-time outside
Yukon remain eligible for the duration of their academic studies.
The Director, Insured Health and Hearing Services (the Director)
may approve other absences in excess of 12 consecutive months
upon receiving a written request from the insured person.
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CHAPTER 3: YUKON
Requests for extensions must be renewed yearly and are subject to
approval by the Director.
For temporary workers and missionaries, the Director may
approve absences in excess of 12 consecutive months upon
receiving a written request from the insured person. Requests
for extensions must be renewed yearly and are subject to
approval by the Director.
The provisions regarding coverage during temporary absences
in Canada fully comply with the terms and conditions of
the Interprovincial Agreement on Eligibility and Portability
effective February 1, 2001. Definitions are consistent in
regulations, policies and procedures.
Yukon participates fully with the Interprovincial Medical
Reciprocal Billing Agreements and Hospital Reciprocal Billing
Agreements in place with all other provinces and territories
with the exception of Quebec, which does not participate in
the medical reciprocal billing arrangement. Persons receiving
medical (physician) services in Quebec may be required to pay
directly and submit claims to the Yukon Health Care Insurance
Plan for reimbursement.
The Hospital Reciprocal Billing Agreements provide for
payment of insured in-patient and out-patient hospital services
to eligible residents receiving insured services outside Yukon,
but within Canada.
The Medical Reciprocal Billing Agreements provide for
payment of insured physician services on behalf of eligible
residents receiving insured services outside Yukon, but within
Canada. Payment is made to the host province at the rates
established by that province.
Insured services provided to Yukon residents while temporarily
absent from the territory are paid at the rates established by the
host province.
4.3 Coverage During Temporary Absences
Outside Canada
The provisions that define portability of health care insurance
to insured persons during temporary absences outside Canada
are defined in sections 5, 6, 7, 9, 10 and 11 of the Yukon Health
Care Insurance Plan Regulations and sections 6, 7(1), 7(2)
and 9 of the Yukon Hospital Insurance Services Regulations.
Sections 5 and 6 currently state that, where an insured person
is absent from Yukon and intends to return, he is entitled to
insured services during a period of 12 months continuous
absence. Similarly to general temporary absences, regulatory
work on coverage during temporary absences outside Canada
is currently underway and will receive further public input prior
to enacting changes.
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Persons leaving Yukon for a period exceeding three months
are advised to contact Yukon Health Care Insurance Plan and
complete a Temporary Absence form. Failure to do so may
result in cancellation of the coverage.
The provisions for portability of health insurance during
out-of-country absences for students, temporary workers
and missionaries are the same as for absences within Canada
(see section 4.2 of this report).
Insured physician services provided to eligible Yukon residents
temporarily outside the country are paid at rates equivalent
to those paid had the service been provided in Yukon.
Reimbursement is made to the insured person by the Yukon
Health Care Insurance Plan or directly to the provider of the
insured service.
Insured in-patient hospital services provided to eligible Yukon
residents outside Canada are paid at the rate established in
the Standard Ward Rates Regulation for the Whitehorse
General Hospital.
Insured out-patient hospital services provided to eligible Yukon
residents outside Canada are paid at the rate established in the
Charges for Out-Patient Procedures Regulation.
4.4 Prior Approval Requirement
There is no legislated requirement that eligible residents must
seek prior approval before seeking elective or emergency
hospital or physician services outside Yukon or outside Canada.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
There are no user fees or co-insurance charges under the Yukon
Health Care Insurance Plan or the Yukon Hospital Insurance
Services Plan. All services are provided on a uniform basis
and are not impeded by financial or other barriers. There is
no extra-billing in Yukon for any services covered by the Plan.
Access to hospital or physician services not available locally are
provided through the Visiting Specialist Program, Telehealth
Program or the Travel for Medical Treatment Program. These
programs ensure that there is minimal or no delay in receiving
medically necessary services.
To improve access to insured health services, the number of
visiting specialists continues to increase to better serve patients
in the territory.
CHAPTER 3: YUKON
The Referred Care Clinic received additional funding to
increase operations to full time hours and increase mental
health nursing hours to full-time to enhance outreach services.
Both of these initiatives will increase residents’ access to
medical care and reduce the reliance and strain placed upon the
Emergency Department at the Whitehorse General Hospital.
5.2 Physician Compensation
The Department of Health and Social Services seeks its
negotiating mandate from the Government of Yukon
before entering into negotiations with the Yukon Medical
Association (YMA). The YMA and the government each
appoint members to the negotiating team. Meetings are
held as required until an agreement has been reached. The
YMA’s negotiating team then seeks approval of the tentative
agreement from the YMA membership. The Department
seeks ratification of the agreement from the Government of
Yukon. The final agreement is signed with the concurrence of
both parties. The current Memorandum of Understanding will
expire on March 31, 2017.
The legislation governing payments to physicians and dentists
for insured services are the Health Care Insurance Plan Act and
the Health Care Insurance Plan Regulations. No amendments
were made to these sections of the legislation in 2014–2015.
The fee-for-service system is used to reimburse the majority
of physicians providing insured services to residents. Other
systems of reimbursement include contract payments and
sessional payments for services in Whitehorse as well as rural
communities in the territory.
5.3 Payments to Hospitals
The Government of Yukon funds the Yukon Hospital
Corporation (Whitehorse General Hospital, Watson Lake
Community Hospital, and Dawson City Community Hospital)
through global contribution agreements with the Department of
Health and Social Services. Global operations and maintenance
(O&M) and capital funding levels are negotiated and adjusted
based on operational requirements and utilization projections
from prior years. In addition to the established O&M and
capital funding set out in the agreement, provision is made
for the hospital to submit requests for additional funding
assistance for implementing new or enhanced programs.
The legislation governing payments made by the health care
plan to facilities that provide insured hospital services is the
Hospital Insurance Services Plan Act and Regulations. The
legislation and regulations set out the legislative framework
for payment to hospitals for insured services provided by
that hospital to insured persons. No amendments were
made to these sections of the legislation in 2014–2015.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
The Government of Yukon has acknowledged the federal
contributions provided through the Canada Health Transfer
(CHT) in its 2014–2015 annual Main Estimates and
Public Accounts publications, which are available publicly.
Section 3(1) (d) and (e) of the Health Care Insurance Plan Act
and section 3 of the Hospital Insurance Services Act acknowledge
the contribution of the Government of Canada.
CANADA HEALTH ACT
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121
CHAPTER 3: YUKON
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
36,063
36,694
37,048
38,054
38,261
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities1
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
15
15
15
15
14
51,734,000
57,655,576
58,943,422
70,087,418
72,452,732
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4. Number of private for-profit facilities
providing insured health services (#).
0
0
0
0
0
5. Payments to private for-profit facilities
for insured health services ($).
0
0
0
0
0
2. Number (#). 2
3. Payments for insured health services ($). 3
Private For-Profit Facilities
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($). 4
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1,047
996
1,173
1,197
1,205
16,583,657
13,507,016
15,890,700
16,562,129
16,703,371
13,197
13,550
14,036
15,493
15,659
3,413,932
3,974,870
4,425,670
4,730,725
5,074,139
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
25
20
18
8
13
45,893
100,716
70,556
39,293
56,722
74
77
61
44
64
12,741
21,950
19,823
9,951
15,889
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
1. Public facilities are the 12 health centres (Beaver Creek, Destruction Bay, Carcross, Carmacks, Faro, Haines Junction, Mayo, Old Crow, Pelly Crossing,
Ross River, Teslin and Whitehorse) and 3 hospitals (Whitehorse, Dawson City and Watson Lake).
2. Watson Lake Nursing Station decommissioned in 2014–2015 with the opening of the new Watson Lake Community Hospital.
3. Includes monies paid to hospitals and community nursing stations.
4. Hospitals have up to a year from date of service to bill jurisdictions. (information is based upon date of service; therefore, 2014–2015 reporting period is still
open until March 31, 2016).
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CHAPTER 3: YUKON
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
69
74
70
71
70
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of not participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($).
21,549,640
22,387,839
22,690,228
24,409,655
26,949,206
18.Total payments for services provided by
physicians paid through fee-for-service ($).5
17,701,880
18,373,627
18,660,715
18,817,879
20,295,869
14.Number of participating physicians (#).
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
54,007
54,073
59,962
57,178
61,331
3,185,612
3,219,166
3,563,528
3,503,179
3,718,480
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
not available
not available
not available
not available
not available
22.Total payments ($).
not available
not available
not available
not available
not available
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
23.Number of participating dentists (#). 6
2
3
3
2
2
24.Number of services provided (#). 6
4
14
26
6
6
4,631
13,913
21,845
3,827
8,117
25.Total payments ($).
5. Includes Visiting Specialists, Member Reimbursements, Locum Doctors, and Optometrist testing paid through fee-for-service. Excludes services and costs
provided by alternative payment agreements.
6. Includes direct billings for insured surgical-dental services received outside the territory.
CANADA HEALTH ACT
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NORTHWEST TERRITORIES
INTRODUCTION
1.0 PUBLIC ADMINISTRATION
The Department of Health and Social Services (DHSS) works
with the eight Health and Social Services Authorities (HSSAs)
to administer, manage, and deliver insured services in the
Northwest Territories (NWT).
1.1 Health Care Insurance Plan and
Public Authority
During the 2014–2015 fiscal year DHSS carried out the
following legislative activities related to health care services:
■■ An Act to Amend the Hospital Insurance and Health and
Social Services Administration Act was introduced. The Bill
will allow for the establishment of a territorial health and
social services authority to replace a number of Boards of
Management. The Bill will also require the Minister of
Health and Social Services to develop a territorial plan
for health and social services. Together these changes are
intended to improve system integration and to increase
system accountability.
■■ A new Health and Social Services Professions Act was
passed. This Act allows for the regulation of several
health and social services professions under one legislative
model. This will allow DHSS to modernize the existing
out-dated professional legislation in a more efficient and
consistent manner.
■■ Work on drafting a new Mental Health Act continued, with
the intent to modernize the legislation. The Act governs
the treatment of persons with mental disorders, including
provisions for involuntary psychiatric assessment, admission
to a hospital and consent to psychiatric treatment.
Additional information on DHSS legislative initiatives is
available in the Health and Social Services Annual Report,
2014–2015.
The Northwest Territories Health Care Plan consists of the
Medical Care Plan and the Hospital Insurance Plan. The public
authority responsible for the administration of the Medical
Care Plan is the Director of Medical Insurance, appointed
by the Minister of Health and Social Services (the Minister),
under the Medical Care Act. The Minister establishes Health
and Social Service Authorities’ Boards of Management as
per section 10 of the Hospital Insurance and Health and Social
Services Administration Act (HIHSSA) to, among other things,
administer the Hospital Insurance Plan.
1.2 Reporting Relationship
There are eight Health and Social Service Authorities
(HSSAs): Tlicho Community Services Agency (TCSA),
Stanton Territorial Health Authority, Yellowknife HSSA,
Sahtu HSSA, Beaufort-Delta HSSA, DehCho HSSA,
Fort Smith HSSA and Hay River HSSA. They report to
the Minister and the Department of Health and Social
Services (DHSS), and plan, manage, deliver and evaluate
a wide spectrum of health and social services at both the
community and facility level throughout the NWT. Boards
of Management for each region manage, control and operate
health and social services facilities within the government’s
existing resources, policies and directives; and are accountable
to the Minister.
The Minister appoints the Director of Medical Insurance who
is responsible for administering the Medical Care Act and its
regulations. The Director prepares an annual report for the
Minister on the operation of the Medical Care Plan. This
report can be found within the DHSS Annual Report.
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CHAPTER 3: NORTHWEST TERRITORIES
Boards of Management are established by the Minister
to administer the Hospital Insurance Plan. The Minister
appoints a chairperson and members to the Board of
Management for each HSSA in the NWT. The chairperson’s
term is indefinite and members serve for three years. The
exception to this is the TCSA where the Tlicho community
governments are responsible for appointing one member to the
Board. The Minister Responsible for Aboriginal Affairs and
Intergovernmental Relations (DAAIR) appoints a chairperson
after consulting with the board members. Members serve for a
maximum of four years and the chairperson’s term is fixed by
the Minister of DAAIR. The Minister may appoint a Public
Administrator to assume the role of a board of management
in certain circumstances if the Minister feels it is necessary
to do so.
■■ radiology and rehab therapy (physio, audio, occupational
The Director of Medical Insurance and the Boards of Man­
agement are responsible to the Minister, as per section 8(1)(b)
of the Canada Health Act.
■■ psychiatric and psychological services under an approved
1.3 Audit of Accounts
As part of the Government of the Northwest Territories annual
audit, the Office of the Auditor General of Canada audits
payments under the Hospital Insurance Plan and the Medical
Care Plan.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
Insured hospital services in the Northwest Territories (NWT)
are provided under the Hospital Insurance and Health and Social
Services Administration Act.
During the reporting period, insured hospital services were
provided to in-patients and out-patients by 27 health facilities
throughout the NWT. Consistent with Section 9 of the Canada
Health Act, the NWT offers a comprehensive range of services
to its residents.
Insured in-patient hospital services include:
■■ meals and accommodation at the ward level;
■■ required nursing services;
■■ laboratory, diagnostic and imaging services (along with
necessary interpretations);
■■ drugs, biologicals and other preparations administered
in the hospital;
■■ surgical supplies and use of operating room;
■■ case room and anaesthesiology services;
and speech);
■■ psychiatric and psychological services within an approved
program; and
■■ detoxification at approved centers.
Insured out-patient hospital services include:
■■ laboratory tests;
■■ diagnostic imaging (including interpretations when needed);
■■ physiotherapy, speech and language pathology therapy and
occupational therapy;
■■ minor medical and surgical procedures and related supplies;
and
hospital program.
The Minister may change, add or remove insured hospital
services, and determine whether public consultation will occur.
As outlined in the Government of the NWT Medical Travel
Policy, travel assistance is provided to residents who require
medically necessary insured services that are not available in
their home community or elsewhere in the NWT. This ensures
that residents of the NWT have reasonable access to insured
hospital and physician services.
2.2 Insured Physician Services
The NWT Medical Care Act and the NWT Medical Care
Regulations provide for insured physician services. Services
provided in approved facilities by physicians, nurses, nurse
practitioners and midwives are considered insured services
under the health care plan. These professionals are required
by legislation to be licensed to practice in the NWT under
the Medical Profession Act (physicians), Nursing Profession Act
(nurses and nurse practitioners) and the Midwifery Profession Act
(registered midwives).
For the period 2014–2015, there were 331 licensed physicians
(resident, locum and visiting) operating in the NWT.
Physicians may opt out and collect fees other than under the
Medical Care Plan by providing written notice to the Director
of Medical Insurance. There were no opted-out physicians in
the NWT during the reporting period.
The Medical Care Plan insures all medically necessary physician
services such as:
■■ diagnosis and treatment of illness and injury;
■■ surgery, including anaesthetic services;
■■ obstetrical care, including prenatal and postnatal care; and
■■ eye examinations, treatment and operations provided by
an ophthalmologist.
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The Director of Medical Insurance is responsible for recommending an insured services tariff for services payable by
the NWT Medical Care Plan for the Minister’s approval.
The Minister ultimately determines if services will be added,
altered or removed from the tariff by:
■■ establishing a medical care plan that provides insured services
to insured persons by medical practitioners that will qualify
and enable the NWT to receive transfer payments from the
Government of Canada under the Canada Health Act; and
■■ approving the fees and charges itemized in the tariff that
may be paid in respect to insured services rendered by
medical practitioners in the NWT and the conditions
under which fees and charges are payable.
2.3 Insured Surgical-Dental Services
Licensed oral surgeons may submit claims for insured surgicaldental work in the NWT. The Province of Alberta’s Schedule
of Oral and Maxillofacial Surgery Benefits is used as a guide.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Not all services provided by hospitals, medical practitioners
and dentists are covered under the Health Care Plan. Some
uninsured services include:
compensation acts. These policies are available on their website
at www.wscc.nt.ca.
The process used to make changes to the list of uninsured
hospital, physician and surgical-dental services is described
in sections 2.1 and 2.2.
3.0UNIVERSALITY
3.1Eligibility
The Medical Care Act and the Hospital Insurance and Health and
Social Services Administration Act (HIHSSA) define eligibility
for the NWT Health Care Plan. The NWT uses guidelines
that are consistent with the legislation and Interprovincial
Agreement on Eligibility and Portability to determine
eligibility in order to fulfill obligations of section 10 in
the Canada Health Act.
Individuals ineligible for NWT health care coverage are
members of the Canadian Forces, federal inmates and new
residents who have not completed the minimum waiting
period. For persons moving back to Canada, eligibility is
restored when permanent residency is established.
■■ third party examinations;
In order to register for the NWT Health Care Plan, residents
fill out an application form and provide applicable supporting
documentation (e.g., visa, immigration papers, and proof of
residency). Residents may register prior to the date they become
eligible. Registration is directly linked to eligibility for coverage
and claims are only paid if the client has registered.
■■ group immunizations;
As of March 31, 2015, there were 43,436 individuals registered
with the NWT Health Care Plan.
■■ advice or prescriptions done over the phone;
3.2 Other Categories of Individuals
■■ in-vitro fertilization;
■■ dental services that are not surgical in nature;
■■ medical-legal services;
■■ services rendered to the physician’s family;
■■ dressings, bandages, drugs and other consumables
used at the medical practitioner’s office;
■■ plaster; and
■■ services carried out by people who usually are not
medical practitioners such as osteopaths, naturopaths
and chiropractors. Physiotherapy, psychiatry and
psychological therapies are not covered if delivered
in a non-approved location.
For NWT residents to receive items and/or services that
are generally considered uninsured under the health care
plan, prior approval is required. A Medical Advisor makes
recommendations to the Director of Medical Insurance
regarding the appropriateness of the request.
The Workers’ Safety and Compensation Committee has
several policies that are applied when interpreting workers’
Holders of employment visas, student visas and, in some
cases, visitor visas are covered if they meet the provisions
of the Eligibility and Portability Agreement and guidelines
for health care plan coverage.
4.0PORTABILITY
4.1 Minimum Waiting Period
Waiting periods for persons moving to the NWT are
consistent with the Interprovincial Agreement on Eligibility
and Portability. The waiting period ends the first day of the
third month of residency for those moving permanently to
the NWT, or the first day of the thirteenth month for those
whose work term was for one year and has been extended.
Confirmation of extension may be required.
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4.2 Coverage During Temporary Absences
in Canada
5.0ACCESSIBILITY
Section 4(2) of the Medical Care Act provides NWT residents
with access to insured health coverage while temporarily out of
the NWT but still in Canada, consistent with section 11(1) (b)(i)
of the Canada Health Act. The Department of Health and Social
Services (DHSS) adheres to the Interprovincial Agreement on
Eligibility and Portability as described in the NWT Health
Care Plan Registration Manual.
5.1 Access to Insured Health Services
Once an individual has filled out the Temporary Absence form
and it is approved by DHSS, NWT residents are covered for up
to one year of temporary absence for work, travel or holidays.
Full-time students attending post-secondary school are covered
as well. The full cost of insured services is paid for all services
received in other Canadian jurisdictions.
At the end of 2014–2015, the partnership with Dalhousie
University providing psychiatric service delivery through
telepsychiatry came to an end. During 2014–2015, Dalhousie
psychiatrists were on-site in the NWT for approximately
19 weeks and also provided services via telepsychiatry for
an additional 14 weeks. The program provided all aspects of
psychiatric care, including travel clinics, consultations, and
emergency assessments.
When a valid NWT health care card is produced, most doctor
visits and hospital services are billed directly to the Department.
During the reporting period, 23 million dollars were paid out
for hospital in-patient and out-patient services in other provinces
and territories. Reimbursement guidelines exist for patients
having to pay up front for medically required services.
The NWT participates in both the Hospital Reciprocal Billing
Agreement and the Medical Reciprocal Billing Agreement
with other jurisdictions (except Quebec).
4.3 Coverage During Temporary Absences
Outside Canada
As per section 4(3) of the Medical Care Act and section 11(1)(b) (ii)
of the Canada Health Act, the NWT provides reimbursement
for NWT residents who require medically necessary services
while temporarily outside Canada. Individuals are required
to pay up front and seek reimbursement upon their return to
the NWT. Costs for eligible services rendered outside Canada
will be reimbursed up to the amounts payable in the NWT.
Residents temporarily out of Canada may receive coverage
for up to one year; however, prior approval is required as well
as documentation proving the NWT will be the individual’s
permanent residence upon return.
4.4 Prior Approval Requirement
Prior approval is required for elective services rendered in
other provinces and outside Canada. All services from private
facilities require prior approval as well.
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The Government of the NWT Medical Travel Policy provides
NWT residents with assistance to access medically necessary
insured services not available in their home community
or in the NWT, consistent with section 12(1)(a) of the
Canada Health Act.
Diagnostic Imaging/Picture Archiving Communication
System (DI/PACS) is available everywhere that digital imaging
services are offered. DI/PACS has moved x-rays from film to
digital format. Radiologists in Yellowknife and the south can
review results in as fast as 35 minutes. This ultimately provides
NWT residents with access to specialists in southern Canada
without having to spend extended periods of time away from
home and family.
Extra-billing is not permitted in the NWT, in adherence to
section 18 of the Canada Health Act. The only exception is if
a medical practitioner opts out of the Medical Care Plan and
collects his or her own fees. This did not occur during the
reporting period.
5.2 Physician Compensation
The Department, in close consultation with the NWT Medical
Association, sets physician compensation. Generally, family and
specialist practitioners are compensated through contractual
agreements with the Government of NWT, while the remainder
are compensated on a fee-for-service basis. Fee-for-service rates
in the NWT are itemized in the Insured Services Tariff approved
by the Minister in accordance with the NWT Medical Care Act.
CHAPTER 3: NORTHWEST TERRITORIES
5.3 Payments to Hospitals
Contribution agreements between the Department of Health
and Social Services and the Boards of Management for each
Health and Social Service Authority (HSSA) dictate payments
made to hospitals. Government budgets, resources and levels
of services offered determine the allocated amounts.
Payments to HSSAs providing insured hospital services are
governed under the Hospital Insurance and Health and Social
Services Administration Act and the Financial Administration Act.
A comprehensive budget is used to fund hospitals in the NWT.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
Federal funding from the Canada Health Transfer has been
recognized and reported by the Government of NWT through
the 2014–2015 Main Estimates.
The Main Estimates report (noted above) is presented annually
to the Legislative Assembly and represents the government’s
financial plan.
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CHAPTER 3: NORTHWEST TERRITORIES
REGISTERED PERSONS
1. Number as of March 31st (#).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
43,639
44,216
42,786
41,158
43,436
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#).
5. Payments to private for-profit facilities
for insured health services ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
27
27
27
27
27
54,728,540
57,225,434
1
1
62,112,381
1
62,499,951
1
69,659,642
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
1,102
1,113
1,195
1,065
1,177
14,775,269
15,418,029
17,526,393
15,684,141
18,388,468
10,611
11,666
11,738
11,212
11,930
3,526,527
4,091,858
4,045,450
4,230,076
4,551,119
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
7
12
18
17
5
54,896
38,898
130,376
231,302
14,800
53
46
66
59
30
31,185
22,132
37,765
67,690
37,320
All data are subject to future revisions. Payment information for #3 and # 17 have been restated for all years to better reflect the actual expenditures on hospital and
physician services.
1. Payments for insured health services are estimated and include only those health services occurring within acute care facilities (e.g., hospitals that offer both
in‑patient and outpatient services).
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1
CHAPTER 3: NORTHWEST TERRITORIES
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
14.Number of participating physicians (#).
292
2011–2012
2
284
2012–2013
297
2
2013–2014
297
2
2014–2015
331
2
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of not participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
45,853,657
1,702,628
3
45,872,806
1,637,565
3
48,171,561
1,460,809
3
50,711,751
53,456,730
3
1,207,816
1,543,900
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
36,728
43,007
49,134
48,104
48,692
4,944,840
4,591,143
5,336,700
5,184,693
5,578,109
19.Number of services (#).
20.Total payments ($).
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
117
102
115
111
66
14,825
9,841
18,672
11,348
4,820
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
23.Number of participating dentists (#).
not available
not available
not available
not available
not available
24.Number of services provided (#).
not available
not available
not available
not available
not available
25.Total payments ($).
not available
not available
not available
not available
not available
2. Estimate based on total active physicians for each fiscal year.
3. Payments are based on an estimate of expenditures for physician services on NWT residents (including physician remuneration and clinic costs).
CANADA HEALTH ACT
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2
3
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NUNAVUT
INTRODUCTION
The Department of Health faces many unique challenges when
providing for the health and well-being of Nunavummiut.
The population of 36,5851 is approximately 81 percent Inuit,
and 49 percent of the population is under the age of 25 years
(17, 943 people).2 The territory is made up of 25 communities
located across three time zones and divided into three regions:
the Qikiqtaaluk (or Baffin), the Kivalliq and the Kitikmeot.
The Government of Nunavut, where possible, incorporates
Inuit societal values into program and policy development, as
well as into service design and delivery. The delivery of health
services in Nunavut is based on a primary health care model.
Nunavut’s primary health care providers are family physicians,
nurse practitioners, midwives, community health nurses, and
other allied health professionals.
In 2014–2015, the territorial operations and maintenance
budget for the Department of Health was $322,000,000,
including supplementary appropriations. 3 One third of the
Department’s total operational budget was spent on costs
associated with medical travel and treatment provided in
out-of-territory facilities. Nunavut is a vast territory with
a low population density and limited health infrastructure,
for example, diagnostic services; therefore, access to a range
of hospital and specialist services often requires that residents
be sent out of the territory for care.
In 2014–2015 an additional $12,423,000 was allocated to
the Department for capital projects.4 The Department of
Health 2014–2015 capital projects included: the replacement
of the Taloyoak Health Centre and preliminary work on the
replacement of the Arctic Bay Health Centre.5
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
The health care insurance plans of Nunavut, including physician
and hospital services, are administered by the Department of
Health on a non-profit basis.
The Medical Care Act (NWT, 1988 and as duplicated for
Nunavut by section 29 of the Nunavut Act, 1999) governs the
entitlement to and payment of benefits for insured medical
services. The Hospital Insurance and Health and Social Services
Administration Act (NWT, 1988 and as duplicated for Nunavut
by section 29 of the Nunavut Act, 1999) enables the establishment of hospital and other health services.
The Department is responsible for delivering health care services
to Nunavummiut, including the operation of community health
centres, regional health centres, and a hospital. There are three
regional offices that manage the delivery of health services at
a regional level. Iqaluit operations are administered separately.
The Government of Nunavut opted for decentralization to
regional offices to support front-line workers and community
based delivery of a wide range of health programs and services.
1.2 Reporting Relationship
Legislation governing the administration of health services
in Nunavut was carried over from the Northwest Territories
(as Nunavut statutes) pursuant to the Nunavut Act. The Medical
Care Act governs who is covered by the Nunavut Health
Care Plan and the payment of benefits for insured medical
services. Section 23(1) of the Medical Care Act requires the
Minister responsible for the Act to appoint a Director of
Medical Insurance.
1. Nunavut Bureau of Statistics July 1, 2015 http://www.stats.gov.nu.ca/en/Population%20estimate.aspx
2. Nunavut Bureau of Statistics July 1, 2015 http://www.stats.gov.nu.ca/en/Population%20estimate.aspx
3. Department of Health, Division of Finance Freebalance Report
4. 2014/2015 Capital Estimates, Government of Nunavut
5. 2014/2015 Capital Estimates, Government of Nunavut
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The Director is responsible for the administration of the Act
and regulations. Section 24 requires the Director to submit an
annual report on the operation of the Nunavut Health Care
Plan to the Minister for tabling in the Legislative Assembly. On
November 5, 2014 the Director of Medical Insurance Annual
Report 2013–2014 was tabled in the Legislative Assembly.
1.3 Audit of Accounts
The Auditor General of Canada is the auditor of the
Government of Nunavut in accordance with section 30.1
of the Financial Administration Act (Nunavut, 1999). The
Auditor General is required to conduct an annual audit of
the transactions and consolidated financial statements of the
Government of Nunavut. The most recent audited report
was issued October 30, 2014.
Public health services are provided at public health clinics
located in Rankin Inlet and Iqaluit. Public health programing
is provided in the remaining communities through the local
health centre. The Department also operates a Family Practice
Clinic, led by Nurse Practitioners, in Iqaluit.
The Familiy Practice Clinic has the ability to consult physicians
and specialists as needed. It was established in 2006 with
funding from the Primary Health Care Transition Fund,
and has been successful in helping to reduce pressure on the
emergency and out-patient departments of the QGH during
working hours. The clinic provides a steady source of primary
care appointments and initiatives, such as a Diabetes Clinic and
a Sexual Health Program.
The Department is responsible for authorizing, licensing,
inspecting and supervising all health facilities in the territory.
Insured hospital services are provided in Nunavut under the
authority of the Hospital Insurance and Health and Social Services
Administration Act and regulations, sections 2 to 4. No amendments were made to the Act or regulations in 2014–2015.
Insured in-patient hospital services include: accommodation
and meals at the standard ward level; necessary nursing
services; laboratory, radiological and other diagnostic
procedures, together with the necessary interpretations; drugs,
biological and related preparations prescribed by a physician
and administered in hospital; routine surgical supplies; use
of operating room, case-room and anaesthetic facilities; use
of radiotherapy and physiotherapy services where available;
psychiatric services provided under an approved program;
services rendered by persons who are paid by the hospital.
In 2014–2015 insured hospital services were delivered in
28 facilities across Nunavut including: one general hospital
(Iqaluit); two regional health facilities (Rankin Inlet and
Cambridge Bay); 22 community health centres; one public
health facility (Iqaluit); and one family practice clinic (Iqaluit).
Rehabilitative treatment is available through the Timimut
Ikajuksivik Centre located in Iqaluit or via contracted services
in other regions.
Out-patient services include: laboratory tests and x-rays,
including interpretations, when requested by a physician and
performed in an out-patient facility or in an approved hospital;
hospital services in connection with most minor medical and
surgical procedures; physiotherapy, occupational therapy,
limited audiology and speech therapy services in an out-patient
facility or in an approved hospital; and psychiatric services
provided under an approved hospital program.
The Qikiqtani General Hospital (QGH) is currently the only
acute care facility in Nunavut providing a range of in-and outpatient hospital services as defined by the Canada Health Act.
QGH offers 24-hour emergency services, in-patient care
(including obstetrics, pediatrics and palliative care), surgical
services, laboratory services, diagnostic imaging, respiratory
therapy, and health records and information.
The Department makes the determination to add insured
hospital services based on the availability of appropriate
resources, equipment and overall feasibility in accordance
with financial guidelines set by the Department and with the
approval of the Financial Management Board. No new services
were added in 2014–2015 to the list of insured hospital services.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
Currently Rankin Inlet is providing 24-hour care for in-patients;
out-patients receive care by on-call staff. Cambridge Bay is
providing daily clinic hours, and emergency care is available,
on-call, 24-hours a day. There are also a limited number of
birthing beds at both facilities. Other community health centres
provide public health services, out-patient services and urgent
treatment services.
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2.2 Insured Physician Services
The Medical Care Act, section 3(1), and Medical Care Regulations,
section 3, provide for insured physician services in Nunavut. No
amendments were made to the Act or regulations in 2014–2015.
The Nursing Act allows for licensure of nurse practitioners
in Nunavut; this permits nurses to deliver insured services
in Nunavut.
CHAPTER 3: NUNAVUT
Physicians must be in good standing with a College of Physicians
and Surgeons from a Canadian jurisdiction, and be licensed to
practice in Nunavut. The Government of Nunavut’s Medical
Registration Committee currently manages this process for
Nunavut physicians. Nunavut recruits and hires its own family
physicians, and accesses specialist services primarily from its
main referral centres in Ottawa, Winnipeg, and Yellowknife.
Recruitment of full-time family physicians has improved
significantly and there are 26 family physician positions, covered
by a combination of locums and full-time physicians, funded
through the Department, providing over 7,400 days of service
annually across the territory.
Of the 26 full-time family physician positions in Nunavut,
16 are in the Qikiqtaaluk region; 7.5 in the Kivalliq region;
and 2.5 in the Kitikmeot region. There are also 1.5 general
surgeons, 1 anaesthetist, and 1 pediatrician at the QGH.
Visiting specialists, general practitioners and locums also
provide insured physician services; these arrangements are
made by each of the Department’s three regions.
2.3 Insured Surgical-Dental Services
Dentists providing insured surgical-dental services under
the Nunavut Health Care Plan must be licensed pursuant
to the Dental Professions Act (NWT, 1988 and as duplicated
for Nunavut by section 29 of the Nunavut Act, 1999). Billing
numbers are provided for billing the Plan regarding the
provision of insured dental services.
Insured dental services are limited to those dental-surgical
procedures scheduled in the regulations, requiring the unique
capabilities of a hospital for their performance; for example,
orthognathic surgery. Oral surgeons are brought to Nunavut on
a regular basis, but on rare occasions, for medically complicated
situations, patients are flown out of the territory.
The addition of new surgical-dental services to the list of
insured services requires government approval. No new services
were added to the list in 2014–2015.
Physicians can elect to collect fees other than those under the
Medical Care Plan in accordance with section 12(2)(a) or (b)
of the Medical Care Act by notifying the Director in writing.
An election can be revoked the first day of the following
month after a letter to that effect is delivered to the Director.
In 2014–2015, no physicians provided written notice of
this election.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
All physicians practicing in Nunavut are under contract with
the Department. In 2014–2015, 289 physicians provided
service in Nunavut.
Services provided by physicians that are not insured include:
yearly physicals; cosmetic surgery; services that are considered
experimental; prescription drugs; physical examinations done at
the request of a third party; optometric services; dental services
other than specific procedures related to jaw injury or disease;
the services of chiropractors, naturopaths, podiatrists, osteopaths and acupuncture treatments; and physiotherapy, speech
therapy and psychology services received in a facility that is not
an insured out-patient facility (hospital).
Insured physician services refer to all services rendered by medical practitioners that are medically required. Where insured
services are unavailable in some places in Nunavut, the patient
is referred to another jurisdiction to obtain the insured service.
Nunavut has health service agreements with medical and treatment centres in Ottawa, Winnipeg, Churchill, Yellowknife
and Edmonton. These are the out-of-territory sites to which
Nunavut mainly refers its patients to access medical services
not available within the territory.
The addition or deletion of insured physician services requires
government approval. For this, the Director of Medical
Insurance would become involved in negotiations with a
collective group of physicians to discuss the service. Then
the decision of the group would be presented to Cabinet for
approval. No insured physician services were added or deleted
in 2014–2015.
Services provided under the Workers’ Compensation Act
(NWT, 1988 and as duplicated for Nunavut by section 29
of the Nunavut Act, 1999) or other Acts of Canada, except
the Canada Health Act, are excluded.
Services not covered in a hospital include: hospital charges
above the standard ward rate for private or semi-private
accommodation; services that are not medically required, such
as cosmetic surgery; services that are considered experimental;
ambulance charges (except inter-hospital transfers); dental
services, other than specific procedures related to jaw injury
or disease; and alcohol and drug rehabilitation, without
prior approval.
In 2014–2015 the Qikiqtani General Hospital charged a
$2,322 per diem rate for services provided for non-Canadian
resident stays. The inpatient rate charged in Rankin Inlet and
Cambridge Bay was $1,304.
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When residents are sent out of the territory for services, the
Department relies on the policies and procedures guiding that
particular jurisdiction when they provide services to Nunavut
residents that could result in additional costs, only to the extent
that these costs are covered by Nunavut’s Medical Insurance
Plan (see section 4.2 below). Any query or complaint is handled
on an individual basis with the jurisdiction involved.
The Department also administers the Non-Insured Health
Benefits (NIHB) Program, on behalf of Health Canada, for
Inuit and First Nations residents in Nunavut. NIHB covers a
co-payment for medical travel, accommodations and meals at
boarding homes (in Ottawa, Winnipeg, Churchill, Edmonton,
Yellowknife and Iqaluit), prescription drugs, dental treatment,
vision care, medical supplies and prostheses, and a number of
other incidental services.
3.0UNIVERSALITY
3.1Eligibility
Eligibility for the Nunavut Health Care Plan is briefly defined
under sections 3(1), (2), and (3) of the Medical Care Act. The
Department also adheres to the Interprovincial Agreement
on Eligibility and Portability, as well as internal guidelines.
No amendments were made to the Act or regulations
in 2014–2015.
Subject to these provisions, every Nunavut resident is eligible
for and entitled to insured health services on uniform terms
and conditions. A resident means a person lawfully entitled to
be in or to remain in Canada, who makes his or her home and
is ordinarily present in Nunavut, but does not include a tourist,
transient or visitor to Nunavut. Eligible residents receive a
health card with a unique health care number.
Registration requirements include a completed application form
and supporting documentation. A health care card is issued to
each resident. To streamline document processing, a staggered
renewal process is used. No premiums exist. Coverage under
the Nunavut Medical Insurance Plan is linked to verification of
registration, although every effort is made to ensure registration
occurs when a coverage issue arises for an eligible resident. For
non-residents, a valid health care card from their home province
or territory is required.
Coverage generally begins the first day of the third month after
arrival in Nunavut, but first-day coverage is provided under
a number of circumstances, for example, newborns whose
mothers or fathers are eligible for coverage. Permanent residents (landed immigrants), returning Canadians, repatriated
Canadians, returning permanent residents, and non-Canadians
who have been issued an employment visa for a period of
12 months or more, are also granted first-day coverage.
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CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
Members of the Canadian Armed Forces and inmates of a
federal penitentiary are not eligible for registration. These
groups are granted first-day coverage under the Nunavut
Health Care Plan upon discharge.
Pursuant to section 7 of the Interprovincial Agreement on
Eligibility and Portability, individuals in Nunavut who are
temporarily absent from their home province or territory and
who are not establishing residency in Nunavut remain covered
by their home provincial or territorial health insurance plans
for up to one year.
On March 31, 2015, 36,667 individuals were registered with
the Nunavut Health Care Plan, up by 1350 from the previous
year. There are no formal provisions for Nunavut residents to
opt out of the Nunavut Health Care Plan.
3.2 Other Categories of Individuals
Non-Canadian holders of employment visas of less than
12 months, foreign students with visas of less than 12 months,
transient workers, and individuals holding a Minister’s Permit
(with the possible exception of those holding a temporary
resident permit who may be reviewed on a case by case basis)
are not eligible for coverage. When unique circumstances occur,
assessments are done on an individual basis. This is consistent
with section 15 of the Northwest Territories’ Guidelines for
Health Care Plan Registration, which was adopted by Nunavut
in 1999.
4.0PORTABILITY
4.1 Minimum Waiting Period
Consistent with section 3 of the Interprovincial Agreement on
Eligibility and Portability, the waiting period before coverage
begins for individuals moving within Canada is three months,
or the first day of the third month following the establishment
of residency in a new province or territory, or the first day of
the third month when an individual, who has been temporarily
absent from his or her home province, decides to take up permanent residency in Nunavut.
4.2 Coverage During Temporary Absences
in Canada
The Medical Care Act, section 4(2), prescribes the benefits
payable where insured medical services are provided outside
Nunavut, but within Canada. The Hospital Insurance and
Health and Social Services Administration Act, sections 5(d) and
28(1)(j)(o), provide the authority for the Minister to enter into
agreements with other jurisdictions to provide health services
to Nunavut residents, and the terms and conditions of payment.
CHAPTER 3: NUNAVUT
No legislative or regulatory changes were made in 2014–2015
with respect to coverage outside Nunavut.
Students studying outside Nunavut must notify the
Department and provide proof of enrollment to ensure
continuing coverage. Requests for extensions must be
renewed yearly and are subject to approval by the Director.
Temporary absences for work, vacation or other reasons for
up to one year are approved by the Director upon receipt of
a written request from the insured person. The Director may
approve absences in excess of 12 continuous months upon
receiving a written request from the insured individual.
The provisions regarding coverage during temporary absences
in Canada fully comply with the terms and conditions of the
Interprovincial Agreement on Eligibility and Portability.
Nunavut participates in physician and hospital reciprocal
billing. As well, special bilateral agreements are in place with
Ontario, Manitoba, Alberta, and the Northwest Territories.
The Hospital Reciprocal Billing Agreements provide payment
of in- and out-patient hospital services to eligible Nunavut
residents receiving insured services outside the territory.
High-cost procedure rates, newborn rates, and out-patient
rates are based on those established by the Interprovincial
Health Insurance Agreements Coordinating Committee.
The Physician Reciprocal Billing Agreements provide payment
of insured physician services on behalf of eligible Nunavut
residents receiving insured services outside the territory.
Payment is made to the host province at the rates established
by that province.
4.3 Coverage During Temporary Absences
Outside Canada
The Medical Care Act, section 4(3), prescribes the benefits
payable where insured medical services are provided outside
Canada. The Hospital Insurance and Health and Social Services
Administration Act, section 28(1)(j)(o), provides the authority
for the Minister to set the terms and conditions of payment
for services provided to Nunavut residents outside Canada.
Individuals are granted coverage for up to one year if they are
temporarily out of the country for any reason, although they
must give prior notice in writing. For services provided to
residents who have been referred out of the country for highly
specialized procedures unavailable in Nunavut and Canada,
Nunavut will pay the full cost. For non-referred or emergency
services, the payment for hospital services is $2,322 per day
and for out-patient care it is $288 per day.
Insured physician services provided to eligible residents
temporarily outside the country are paid at rates equivalent
to those paid had that service been provided in the territory.
Reimbursement is made to the insured individual or directly
to the provider of the insured service.
4.4 Prior Approval Requirement
Prior approval is required for elective services provided in private facilities in Canada or in any facility outside the country.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
The Medical Care Act, section 14, prohibits extra-billing by
physicians unless the medical practitioner has made an election
that is still in effect. Access to insured services is provided on
uniform terms and conditions. To break down the barrier posed
by distance and cost of travel, the Government of Nunavut
provides medical travel assistance. Interpretation services in
Inuktut are also provided to patients in any health care setting.
The Qikiqtani General Hospital (QGH) in Iqaluit is currently
the only acute care hospital facility in Nunavut. The hospital
has a total of 35 beds available for acute, rehabilitative,
palliative and chronic care services and currently 20 general
purpose beds are in use due to capacity and need. There are
also four birthing rooms and six day surgery beds. The facility
provides in-patient, out-patient and 24-hour emergency
services. On-site physicians provide emergency services on
rotation. Medical services provided include: an ambulatory
care/out-patient clinic, limited intensive care services, and
general medical, maternity and palliative care. Surgical services
provided include ophthalmology, urology, orthopaedics,
gynaecology, paediatrics, general surgery, emergency trauma,
otolaryngology and dental surgery under general anesthesia
and conscious sedation. Patients requiring specialized surgeries
are sent to other jurisdictions. Diagnostic services include:
radiology, laboratory, electrocardiogram and CT scans.
Outside of Iqaluit, out-patient and 24-hour emergency nursing
services are provided by local health centres in Nunavut’s
24 other communities.
Nunavut has two Continuing Care Centres located in Igloolik
and Gjoa Haven. These facilities provide full time nursing and
personal care to adults. Each facility has 10 beds.
Nunavut has agreements in place with a number of out-ofterritory regional health authorities and specific facilities to
provide medical specialists and other visiting health practitioner
services. The following specialist services were provided in
Nunavut during 2014–2015 under the visiting specialists
program: ophthalmology, orthopaedics, internal medicine,
otolaryngology, neurology, rheumatology, dermatology,
paediatrics, obstetrics/gynecology, urology, respirology,
cardiology, physiotherapy, occupational therapy, psychiatry,
oral surgery, and allergist. Visiting specialist clinics are held
depending on demand and availability of specialists.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
137
CHAPTER 3: NUNAVUT
Nunavut’s Telehealth network, linking all 25 communities,
allows for the delivery of a broad range of services over
distances including specialist consultation services such as
dermatology, psychiatry and internal medicine; rehabilitation
services; regularly scheduled counseling sessions; family
visitation; and continuing medical education. The long-term
goal is to integrate Telehealth into the primary care delivery
system, enabling residents of Nunavut greater access to a
broader range of service options, and allowing service providers
and communities to use existing resources more effectively.
5.3 Payments to Hospitals
For services and equipment unavailable in Nunavut, patients are
referred to other jurisdictions.
Nunavummiut are aware of ongoing federal contributions
through press releases and media coverage. The Government of
Nunavut has also recognized the federal contribution provided
through the Canada Health Transfer in various published
documents. For fiscal year 2014–2015, they included:
5.2 Physician Compensation
All full-time physicians in Nunavut work under contract with
the Department. The terms of the contracts are set by the
Department. Visiting consultants are paid a daily contract
rate for their professional services. Rates vary based on
services rendered.
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CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
Funding for the Qikiqtani General Hospital, regional health
facilities and community health centres is provided through the
Government of Nunavut’s budget process.
6.0RECOGNITION GIVEN TO
FEDERAL TRANSFERS
■■ 2014–2015 Budget Address; and
■■ 2015–2018 Government of Nunavut Business Plan.
CHAPTER 3: NUNAVUT
REGISTERED PERSONS
1. Number as of March 31st (#).1
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
35,515
35,893
35,041
35,897
36,667
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
Public Facilities
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
28
28
28
28
28
not available
not available
not available
not available
not available
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
4. Number of private for-profit facilities
providing insured health services (#).
0
0
0
0
0
5. Payments to private for-profit facilities
for insured health services ($).
0
0
0
0
0
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
2,924
3,406
3,313
3,360
3,230
28,527,577
38,486,274
39,244,449
37,494,619
33,499,713
18,352
22,725
21,686
22,113
25,658
6,318,885
8,975,802
7,780,896
8,297,900
9,421,495
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA
10.Total number of claims, in-patient (#).
0
0
1
1
0
11. Total payments, in-patient ($).
0
0
4,410
20,574
0
12.Total number of claims, out-patient (#).
0
0
0
20
14
13.Total payments, out-patient ($).
0
0
0
20,041
25,388
1. The difference in the number of registered Nunavut residents and those covered under the Nunavut Health Care Plan is due to delays in the reconciliation of data
on residents who have left the territory.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
139
CHAPTER 3: NUNAVUT
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
225
375
409
349
289
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of not participating physicians (#).
0
0
0
0
0
not available
not available
not available
not available
not available
312,786
334,539
403,418
348,473
54,501
14.Number of participating physicians (#).
17. Total payments for services provided
by physicians paid through all payment
methods ($). 3
18.Total payments for services provided by
physicians paid through fee-for-service ($).2,3
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY
19.Number of services (#).
20.Total payments ($). 4
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
73,564
75,108
80,311
80,682
96,070
5,901,962
6,393,341
6,341,047
6,855,743
7,607,809
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA
21.Number of services (#).
22.Total payments ($).
53
22
15
82
29
1,575
963
732
7,346
1,803
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY
2010–2011
2011–2012
2012–2013
2013–2014
2014–2015
23.Number of participating dentists (#).
not available
not available
not available
not available
not available
24.Number of services provided (#).
not available
not available
not available
not available
not available
25.Total payments ($).
not available
not available
not available
not available
not available
2. Typically, Nunavut does not pay its physicians through fee-for-service. Instead, the majority of physicians are compensated through contracted salaries.
3. Fee-for-service is lower in 2014–2015 due to a new radiology contract.
4. For 2014–15 this is the amount as of August 2015. Bills are accepted until March 2016.
140
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
ANNEX A
CANADA HEALTH ACT AND
EXTRA-BILLING AND USER
CHARGES INFORMATION
REGULATIONS
This annex provides the reader with an office consolidation of
the Canada Health Act and the Extra-billing and User Charges
Information Regulations. An office consolidation is a rendering
of the original Act, which includes any amendments that have
been made since the Act’s passage. The only regulations in
force under the Act are the Extra-billing and User Charges
Information Regulations. These regulations require the
provinces and territories to provide estimates of extra-billing
and user charges prior to the beginning of each fiscal year so
that appropriate penalties can be levied, as well as financial
statements showing the amounts actually charged so that
reconciliations with any estimated charges can be made. These
regulations are also presented in an office consolidation format.
This unofficial consolidation is current to July 8, 2012. It is
provided for the convenience of the reader only. For the official
text of the Canada Health Act, please contact Justice Canada.
CANADA HEALTH ACT
ANNUAL REPORT 2014–2015
141
142
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
CANADA
CANADA
CONSOLIDATION
CODIFICATION
Canada Health Act
Loi canadienne sur la
santé
R.S.C., 1985, c. C-6
L.R.C., 1985, ch. C-6
Current to July 8, 2012
À jour au 8 juillet 2012
Last amended on June 29, 2012
Dernière modification le 29 juin 2012
Published by the Minister of Justice at the following address:
http://laws-lois.justice.gc.ca
Publié par le ministre de la Justice à l’adresse suivante :
http://lois-laws.justice.gc.ca
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
143
Published
consolidation is
evidence
Inconsistencies
in Acts
144
OFFICIAL STATUS
OF CONSOLIDATIONS
CARACTÈRE OFFICIEL
DES CODIFICATIONS
Subsections 31(1) and (2) of the Legislation
Revision and Consolidation Act, in force on
June 1, 2009, provide as follows:
Les paragraphes 31(1) et (2) de la Loi sur la
révision et la codification des textes législatifs,
en vigueur le 1er juin 2009, prévoient ce qui
suit :
31. (1) Every copy of a consolidated statute or
consolidated regulation published by the Minister
under this Act in either print or electronic form is evidence of that statute or regulation and of its contents
and every copy purporting to be published by the
Minister is deemed to be so published, unless the
contrary is shown.
31. (1) Tout exemplaire d'une loi codifiée ou d'un
règlement codifié, publié par le ministre en vertu de
la présente loi sur support papier ou sur support électronique, fait foi de cette loi ou de ce règlement et de
son contenu. Tout exemplaire donné comme publié
par le ministre est réputé avoir été ainsi publié, sauf
preuve contraire.
(2) In the event of an inconsistency between a
consolidated statute published by the Minister under
this Act and the original statute or a subsequent
amendment as certified by the Clerk of the Parliaments under the Publication of Statutes Act, the original statute or amendment prevails to the extent of
the inconsistency.
(2) Les dispositions de la loi d'origine avec ses
modifications subséquentes par le greffier des Parlements en vertu de la Loi sur la publication des lois
l'emportent sur les dispositions incompatibles de la
loi codifiée publiée par le ministre en vertu de la présente loi.
NOTE
NOTE
This consolidation is current to July 8, 2012. The last
amendments came into force on June 29, 2012. Any
amendments that were not in force as of July 8, 2012
are set out at the end of this document under the
heading “Amendments Not in Force”.
Cette codification est à jour au 8 juillet 2012. Les
dernières modifications sont entrées en vigueur
le 29 juin 2012. Toutes modifications qui n'étaient
pas en vigueur au 8 juillet 2012 sont énoncées à la
fin de ce document sous le titre « Modifications non
en vigueur ».
Codifications
comme élément
de preuve
Incompatibilité
— lois
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
Preamble
R.S.C., 1985, c. C-6
L.R.C., 1985, ch. C-6
An Act relating to cash contributions by
Canada and relating to criteria and
conditions in respect of insured health
services and extended health care services
Loi concernant les contributions pécuniaires du
Canada ainsi que les principes et
conditions applicables aux services de
santé
assurés
et
aux
services
complémentaires de santé
WHEREAS the Parliament of Canada recognizes:
Considérant que le Parlement du Canada reconnaît :
—that it is not the intention of the Government of Canada that any of the powers,
rights, privileges or authorities vested in
Canada or the provinces under the provisions
of the Constitution Act, 1867, or any amendments thereto, or otherwise, be by reason of
this Act abrogated or derogated from or in
any way impaired;
que le gouvernement du Canada n’entend
pas par la présente loi abroger les pouvoirs,
droits, privilèges ou autorités dévolus au
Canada ou aux provinces sous le régime de
la Loi constitutionnelle de 1867 et de ses modifications ou à tout autre titre, ni leur déroger ou porter atteinte,
—that Canadians, through their system of insured health services, have made outstanding
progress in treating sickness and alleviating
the consequences of disease and disability
among all income groups;
que les Canadiens ont fait des progrès remarquables, grâce à leur système de services de
santé assurés, dans le traitement des maladies
et le soulagement des affections et déficiences parmi toutes les catégories socioéconomiques,
—that Canadians can achieve further improvements in their well-being through combining individual lifestyles that emphasize
fitness, prevention of disease and health promotion with collective action against the social, environmental and occupational causes
of disease, and that they desire a system of
health services that will promote physical
and mental health and protection against disease;
que les Canadiens peuvent encore améliorer
leur bien-être en joignant à un mode de vie
individuel axé sur la condition physique, la
prévention des maladies et la promotion de la
santé, une action collective contre les causes
sociales, environnementales ou industrielles
des maladies et qu’ils désirent un système de
services de santé qui favorise la santé physique et mentale et la protection contre les
maladies,
—that future improvements in health will require the cooperative partnership of governments, health professionals, voluntary organizations and individual Canadians;
que les améliorations futures dans le domaine de la santé nécessiteront la coopération des gouvernements, des professionnels
de la santé, des organismes bénévoles et des
citoyens canadiens,
—that continued access to quality health care
without financial or other barriers will be
critical to maintaining and improving the
health and well-being of Canadians;
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
Préambule
que l’accès continu à des soins de santé de
qualité, sans obstacle financier ou autre, sera
déterminant pour la conservation et l’amélioration de la santé et du bien-être des Canadiens;
1
145
Canada Health — July 8, 2012
Short title
AND WHEREAS the Parliament of Canada
wishes to encourage the development of health
services throughout Canada by assisting the
provinces in meeting the costs thereof;
considérant en outre que le Parlement du
Canada souhaite favoriser le développement
des services de santé dans tout le pays en aidant
les provinces à en supporter le coût,
NOW, THEREFORE, Her Majesty, by and
with the advice and consent of the Senate and
House of Commons of Canada, enacts as follows:
Sa Majesté, sur l’avis et avec le consentement
du Sénat et de la Chambre des communes du
Canada, édicte :
SHORT TITLE
TITRE ABRÉGÉ
1. This Act may be cited as the Canada
Health Act.
1. Loi canadienne sur la santé.
Titre abrégé
1984, ch. 6, art. 1.
1984, c. 6, s. 1.
INTERPRETATION
Definitions
DÉFINITIONS
2. In this Act,
“Act of 1977” [Repealed, 1995, c. 17, s. 34]
“cash
contribution”
« contribution
pécuniaire »
“cash contribution” means the cash contribution in respect of the Canada Health Transfer
that may be provided to a province under sections 24.2 and 24.21 of the Federal-Provincial
Fiscal Arrangements Act;
“dentist” means a person lawfully entitled to
practise dentistry in the place in which the
practice is carried on by that person;
“extended health
care services”
« services
complémentaires
de santé »
“extended health care services” means the following services, as more particularly defined in
the regulations, provided for residents of a
province, namely,
« assuré »
“insured
person”
c) des personnes purgeant une peine d’emprisonnement dans un pénitencier, au sens de
la Partie I de la Loi sur le système correctionnel et la mise en liberté sous condition;
d) des habitants de la province qui s’y
trouvent depuis une période de temps inférieure au délai minimal de résidence ou de
carence d’au plus trois mois imposé aux habitants par la province pour qu’ils soient admissibles ou aient droit aux services de santé
assurés.
(b) adult residential care service,
« contribution » [Abrogée, 1995, ch. 17, art. 34]
(c) home care service, and
(d) ambulatory health care service;
“health care
insurance plan”
« régime
d’assurancesanté »
« assuré » Habitant d’une province, à l’exception :
b) [Abrogé, 2012, ch. 19, art. 377]
(a) nursing home intermediate care service,
“extra-billing”
« surfacturation »
Définitions
a) des membres des Forces canadiennes;
“contribution” [Repealed, 1995, c. 17, s. 34]
“dentist”
« dentiste »
2. Les définitions qui suivent s’appliquent à
la présente loi.
“extra-billing” means the billing for an insured
health service rendered to an insured person by
a medical practitioner or a dentist in an amount
in addition to any amount paid or to be paid for
that service by the health care insurance plan of
a province;
“health care insurance plan” means, in relation
to a province, a plan or plans established by the
law of the province to provide for insured
health services;
146
« contribution pécuniaire » La contribution au
titre du Transfert canadien en matière de santé
qui peut être versée à une province au titre des
articles 24.2 et 24.21 de la Loi sur les arrangements fiscaux entre le gouvernement fédéral et
les provinces.
« contribution
pécuniaire »
“cash
contribution”
« dentiste » Personne légalement autorisée à
exercer la médecine dentaire au lieu où elle se
livre à cet exercice.
« dentiste »
“dentist”
« frais modérateurs » Frais d’un service de santé
assuré autorisés ou permis par un régime provincial d’assurance-santé mais non payables,
« frais
modérateurs »
“user charge”
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
2
Santé — 8 juillet 2012
“health care
practitioner”
« professionnel
de la santé »
“health care practitioner” means a person lawfully entitled under the law of a province to
provide health services in the place in which
the services are provided by that person;
soit directement soit indirectement, au titre
d’un régime provincial d’assurance-santé, à
l’exception des frais imposés par surfacturation.
“hospital”
« hôpital »
“hospital” includes any facility or portion
thereof that provides hospital care, including
acute, rehabilitative or chronic care, but does
not include
« habitant » Personne domiciliée et résidant habituellement dans une province et légalement
autorisée à être ou à rester au Canada, à l’exception d’une personne faisant du tourisme, de
passage ou en visite dans la province.
« habitant »
“resident”
« hôpital » Sont compris parmi les hôpitaux tout
ou partie des établissements où sont fournis des
soins hospitaliers, notamment aux personnes
souffrant de maladie aiguë ou chronique ainsi
qu’en matière de réadaptation, à l’exception :
« hôpital »
“hospital”
(a) a hospital or institution primarily for the
mentally disordered, or
(b) a facility or portion thereof that provides
nursing home intermediate care service or
adult residential care service, or comparable
services for children;
“hospital
services”
« services
hospitaliers »
a) des hôpitaux ou institutions destinés principalement aux personnes souffrant de
troubles mentaux;
“hospital services” means any of the following
services provided to in-patients or out-patients
at a hospital, if the services are medically necessary for the purpose of maintaining health,
preventing disease or diagnosing or treating an
injury, illness or disability, namely,
b) de tout ou partie des établissements où
sont fournis des soins intermédiaires en maison de repos ou des soins en établissement
pour adultes ou des soins comparables pour
les enfants.
(a) accommodation and meals at the standard or public ward level and preferred accommodation if medically required,
« loi de 1977 » [Abrogée, 1995, ch. 17, art. 34]
(b) nursing service,
(c) laboratory, radiological and other diagnostic procedures, together with the necessary interpretations,
(d) drugs, biologicals and related preparations when administered in the hospital,
(e) use of operating room, case room and
anaesthetic facilities, including necessary
equipment and supplies,
(f) medical and surgical equipment and supplies,
(g) use of radiotherapy facilities,
(h) use of physiotherapy facilities, and
(i) services provided by persons who receive
remuneration therefor from the hospital,
« médecin »
“medical
practitioner”
« ministre » Le ministre de la Santé.
« ministre »
“Minister”
« professionnel de la santé » Personne légalement autorisée en vertu de la loi d’une province
à fournir des services de santé au lieu où elle
les fournit.
« professionnel
de la santé »
“health care
practitioner”
« régime d’assurance-santé » Le régime ou les
régimes constitués par la loi d’une province en
vue de la prestation de services de santé assurés.
« régime
d’assurancesanté »
“health care
insurance plan”
« services complémentaires de santé » Les services définis dans les règlements et offerts aux
habitants d’une province, à savoir :
« services
complémentaires
de santé »
“extended health
care services”
a) les soins intermédiaires en maison de repos;
but does not include services that are excluded
by the regulations;
“insured health
services”
« services de
santé assurés »
« médecin » Personne légalement autorisée à
exercer la médecine au lieu où elle se livre à cet
exercice.
b) les soins en établissement pour adultes;
“insured health services” means hospital services, physician services and surgical-dental
services provided to insured persons, but does
not include any health services that a person is
entitled to and eligible for under any other Act
of Parliament or under any Act of the legisla-
c) les soins à domicile;
d) les soins ambulatoires.
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ture of a province that relates to workers' or
workmen’s compensation;
“insured person”
« assuré »
“insured person” means, in relation to a
province, a resident of the province other than
(a) a member of the Canadian Forces,
(b) [Repealed, 2012, c. 19, s. 377]
(c) a person serving a term of imprisonment
in a penitentiary as defined in the Penitentiary Act, or
(d) a resident of the province who has not
completed such minimum period of residence or waiting period, not exceeding three
months, as may be required by the province
for eligibility for or entitlement to insured
health services;
“medical
practitioner”
« médecin »
“medical practitioner” means a person lawfully
entitled to practise medicine in the place in
which the practice is carried on by that person;
“Minister”
« ministre »
“Minister” means the Minister of Health;
“physician
services”
« services
médicaux »
“physician services” means any medically required services rendered by medical practitioners;
“resident”
« habitant »
“resident” means, in relation to a province, a
person lawfully entitled to be or to remain in
Canada who makes his home and is ordinarily
present in the province, but does not include a
tourist, a transient or a visitor to the province;
“surgical-dental
services”
« services de
chirurgie
dentaire »
“surgical-dental services” means any medically
or dentally required surgical-dental procedures
performed by a dentist in a hospital, where a
hospital is required for the proper performance
of the procedures;
“user charge”
« frais
modérateurs »
“user charge” means any charge for an insured
health service that is authorized or permitted by
a provincial health care insurance plan that is
not payable, directly or indirectly, by a provincial health care insurance plan, but does not include any charge imposed by extra-billing.
« services de chirurgie dentaire » Actes de chirurgie dentaire nécessaires sur le plan médical
ou dentaire, accomplis par un dentiste dans un
hôpital, et qui ne peuvent être accomplis convenablement qu’en un tel établissement.
« services de
chirurgie
dentaire »
“surgical-dental
services”
« services de santé assurés » Services hospitaliers, médicaux ou de chirurgie dentaire fournis
aux assurés, à l’exception des services de santé
auxquels une personne a droit ou est admissible
en vertu d’une autre loi fédérale ou d’une loi
provinciale relative aux accidents du travail.
« services de
santé assurés »
“insured health
services”
« services hospitaliers » Services fournis dans
un hôpital aux malades hospitalisés ou externes, si ces services sont médicalement nécessaires pour le maintien de la santé, la prévention des maladies ou le diagnostic ou le
traitement des blessures, maladies ou invalidités, à savoir :
« services
hospitaliers »
“hospital
services”
a) l’hébergement et la fourniture des repas
en salle commune ou, si médicalement nécessaire, en chambre privée ou semi-privée;
b) les services infirmiers;
c) les actes de laboratoires, de radiologie ou
autres actes de diagnostic, ainsi que les interprétations nécessaires;
d) les produits pharmaceutiques, substances
biologiques et préparations connexes administrés à l’hôpital;
e) l’usage des salles d’opération, des salles
d’accouchement et des installations d’anesthésie, ainsi que le matériel et les fournitures
nécessaires;
f) le matériel et les fournitures médicaux et
chirurgicaux;
g) l’usage des installations de radiothérapie;
h) l’usage des installations de physiothérapie;
i) les services fournis par les personnes rémunérées à cet effet par l’hôpital.
R.S., 1985, c. C-6, s. 2; 1992, c. 20, s. 216(F); 1995, c. 17,
s. 34; 1996, c. 8, s. 32; 1999, c. 26, s. 11; 2012, c. 19, ss.
377, 407.
Ne sont pas compris parmi les services hospitaliers les services exclus par les règlements.
148
« services médicaux » Services médicalement
nécessaires fournis par un médecin.
« services
médicaux »
“physician
services”
« surfacturation » Facturation de la prestation à
un assuré par un médecin ou un dentiste d’un
« surfacturation »
“extra-billing”
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service de santé assuré, en excédent par rapport
au montant payé ou à payer pour la prestation
de ce service au titre du régime provincial d’assurance-santé.
L.R. (1985), ch. C-6, art. 2; 1992, ch. 20, art. 216(F); 1995,
ch. 17, art. 34; 1996, ch. 8, art. 32; 1999, ch. 26, art. 11;
2012, ch. 19, art. 377 et 407.
Primary
objective of
Canadian health
care policy
Purpose of this
Act
CANADIAN HEALTH CARE POLICY
POLITIQUE CANADIENNE DE LA SANTÉ
3. It is hereby declared that the primary objective of Canadian health care policy is to protect, promote and restore the physical and mental well-being of residents of Canada and to
facilitate reasonable access to health services
without financial or other barriers.
3. La politique canadienne de la santé a pour
premier objectif de protéger, de favoriser et
d’améliorer le bien-être physique et mental des
habitants du Canada et de faciliter un accès satisfaisant aux services de santé, sans obstacles
d’ordre financier ou autre.
1984, c. 6, s. 3.
1984, ch. 6, art. 3.
PURPOSE
RAISON D’ÊTRE
4. The purpose of this Act is to establish criteria and conditions in respect of insured health
services and extended health care services provided under provincial law that must be met before a full cash contribution may be made.
4. La présente loi a pour raison d’être d’établir les conditions d’octroi et de versement
d’une pleine contribution pécuniaire pour les
services de santé assurés et les services complémentaires de santé fournis en vertu de la loi
d’une province.
R.S., 1985, c. C-6, s. 4; 1995, c. 17, s. 35.
Objectif premier
Raison d’être de
la présente loi
L.R. (1985), ch. C-6, art. 4; 1995, ch. 17, art. 35.
Cash
contribution
CASH CONTRIBUTION
CONTRIBUTION PÉCUNIAIRE
5. Subject to this Act, as part of the Canada
Health Transfer, a full cash contribution is
payable by Canada to each province for each
fiscal year.
5. Sous réserve des autres dispositions de la
présente loi, le Canada verse à chaque province, pour chaque exercice, une pleine contribution pécuniaire à titre d’élément du Transfert
canadien en matière de santé (ci-après, « Transfert »).
R.S., 1985, c. C-6, s. 5; 1995, c. 17, s. 36; 2012, c. 19, s.
408.
Contribution
pécuniaire
L.R. (1985), ch. C-6, art. 5; 1995, ch. 17, art. 36; 2012, ch.
19, art. 408.
6. [Repealed, 1995, c. 17, s. 36]
Program criteria
6. [Abrogé, 1995, ch. 17, art. 36]
PROGRAM CRITERIA
CONDITIONS D’OCTROI
7. In order that a province may qualify for a
full cash contribution referred to in section 5
for a fiscal year, the health care insurance plan
of the province must, throughout the fiscal
year, satisfy the criteria described in sections 8
to 12 respecting the following matters:
7. Le versement à une province, pour un
exercice, de la pleine contribution pécuniaire
visée à l’article 5 est assujetti à l’obligation
pour le régime d’assurance-santé de satisfaire,
pendant tout cet exercice, aux conditions d’octroi énumérées aux articles 8 à 12 quant à :
(a) public administration;
a) la gestion publique;
(b) comprehensiveness;
b) l’intégralité;
(c) universality;
c) l’universalité;
(d) portability; and
d) la transférabilité;
Règle générale
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e) l’accessibilité.
(e) accessibility.
Public
administration
1984, c. 6, s. 7.
1984, ch. 6, art. 7.
8. (1) In order to satisfy the criterion respecting public administration,
8. (1) La condition de gestion publique suppose que :
(a) the health care insurance plan of a
province must be administered and operated
on a non-profit basis by a public authority
appointed or designated by the government
of the province;
a) le régime provincial d’assurance-santé
soit géré sans but lucratif par une autorité publique nommée ou désignée par le gouvernement de la province;
b) l’autorité publique soit responsable devant le gouvernement provincial de cette
gestion;
(b) the public authority must be responsible
to the provincial government for that administration and operation; and
c) l’autorité publique soit assujettie à la vérification de ses comptes et de ses opérations
financières par l’autorité chargée par la loi de
la vérification des comptes de la province.
(c) the public authority must be subject to
audit of its accounts and financial transactions by such authority as is charged by law
with the audit of the accounts of the
province.
Designation of
agency
permitted
Comprehensiveness
Gestion
publique
(2) The criterion respecting public administration is not contravened by reason only that
the public authority referred to in subsection (1)
has the power to designate any agency
(2) La condition de gestion publique n’est
pas enfreinte du seul fait que l’autorité publique
visée au paragraphe (1) a le pouvoir de désigner un mandataire chargé :
(a) to receive on its behalf any amounts
payable under the provincial health care insurance plan; or
a) soit de recevoir en son nom les montants
payables au titre du régime provincial d’assurance-santé;
(b) to carry out on its behalf any responsibility in connection with the receipt or payment
of accounts rendered for insured health services, if it is a condition of the designation
that all those accounts are subject to assessment and approval by the public authority
and that the public authority shall determine
the amounts to be paid in respect thereof.
b) soit d’exercer en son nom les attributions
liées à la réception ou au règlement des
comptes remis pour prestation de services de
santé assurés si la désignation est assujettie à
la vérification et à l’approbation par l’autorité publique des comptes ainsi remis et à la
détermination par celle-ci des montants à
payer à cet égard.
1984, c. 6, s. 8.
1984, ch. 6, art. 8.
9. In order to satisfy the criterion respecting
comprehensiveness, the health care insurance
plan of a province must insure all insured
health services provided by hospitals, medical
practitioners or dentists, and where the law of
the province so permits, similar or additional
services rendered by other health care practitioners.
9. La condition d’intégralité suppose qu’au
titre du régime provincial d’assurance-santé,
tous les services de santé assurés fournis par les
hôpitaux, les médecins ou les dentistes soient
assurés, et lorsque la loi de la province le permet, les services semblables ou additionnels
fournis par les autres professionnels de la santé.
Désignation
d’un mandataire
Intégralité
1984, ch. 6, art. 9.
1984, c. 6, s. 9.
Universality
10. In order to satisfy the criterion respecting universality, the health care insurance plan
of a province must entitle one hundred per cent
of the insured persons of the province to the in-
10. La condition d’universalité suppose
qu’au titre du régime provincial d’assurancesanté, cent pour cent des assurés de la province
ait droit aux services de santé assurés prévus
par celui-ci, selon des modalités uniformes.
Universalité
1984, ch. 6, art. 10.
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sured health services provided for by the plan
on uniform terms and conditions.
1984, c. 6, s. 10.
Portability
11. (1) In order to satisfy the criterion respecting portability, the health care insurance
plan of a province
11. (1) La condition de transférabilité suppose que le régime provincial d’assurancesanté :
(a) must not impose any minimum period of
residence in the province, or waiting period,
in excess of three months before residents of
the province are eligible for or entitled to insured health services;
a) n’impose pas de délai minimal de résidence ou de carence supérieur à trois mois
aux habitants de la province pour qu’ils
soient admissibles ou aient droit aux services
de santé assurés;
(b) must provide for and be administered
and operated so as to provide for the payment of amounts for the cost of insured
health services provided to insured persons
while temporarily absent from the province
on the basis that
b) prévoie et que ses modalités d’application
assurent le paiement des montants pour le
coût des services de santé assurés fournis à
des assurés temporairement absents de la
province :
(i) si ces services sont fournis au Canada,
selon le taux approuvé par le régime d’assurance-santé de la province où ils sont
fournis, sauf accord de répartition différente du coût entre les provinces concernées,
(i) where the insured health services are
provided in Canada, payment for health
services is at the rate that is approved by
the health care insurance plan of the
province in which the services are provided, unless the provinces concerned agree
to apportion the cost between them in a
different manner, or
(ii) s’il sont fournis à l’étranger, selon le
montant qu’aurait versé la province pour
des services semblables fournis dans la
province, compte tenu, s’il s’agit de services hospitaliers, de l’importance de l’hôpital, de la qualité des services et des
autres facteurs utiles;
(ii) where the insured health services are
provided out of Canada, payment is made
on the basis of the amount that would have
been paid by the province for similar services rendered in the province, with due
regard, in the case of hospital services, to
the size of the hospital, standards of service and other relevant factors; and
c) prévoie et que ses modalités d’application
assurent la prise en charge, pendant le délai
minimal de résidence ou de carence imposé
par le régime d’assurance-santé d’une autre
province, du coût des services de santé assurés fournis aux personnes qui ne sont plus assurées du fait qu’elles habitent cette province, dans les mêmes conditions que si elles
habitaient encore leur province d’origine.
(c) must provide for and be administered
and operated so as to provide for the payment, during any minimum period of residence, or any waiting period, imposed by the
health care insurance plan of another
province, of the cost of insured health services provided to persons who have ceased
to be insured persons by reason of having become residents of that other province, on the
same basis as though they had not ceased to
be residents of the province.
Requirement for
consent for
elective insured
health services
permitted
Transférabilité
(2) The criterion respecting portability is not
contravened by a requirement of a provincial
health care insurance plan that the prior consent
of the public authority that administers and operates the plan must be obtained for elective in-
(2) La condition de transférabilité n’est pas
enfreinte du fait qu’il faut, aux termes du régime d’assurance-santé d’une province, le
consentement préalable de l’autorité publique
qui le gère pour la prestation de services de
Consentement
préalable à la
prestation des
services de santé
assurés
facultatifs
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Definition of
"elective insured
health services"
Accessibility
sured health services provided to a resident of
the province while temporarily absent from the
province if the services in question were available on a substantially similar basis in the
province.
santé assurés facultatifs à un habitant temporairement absent de la province, si ces services y
sont offerts selon des modalités sensiblement
comparables.
(3) For the purpose of subsection (2), “elective insured health services” means insured
health services other than services that are provided in an emergency or in any other circumstance in which medical care is required without delay.
(3) Pour l’application du paragraphe (2),
« services de santé assurés facultatifs » s’entend
des services de santé assurés, à l’exception de
ceux qui sont fournis d’urgence ou dans
d’autres circonstances où des soins médicaux
sont requis sans délai.
1984, c. 6, s. 11.
1984, ch. 6, art. 11.
12. (1) In order to satisfy the criterion respecting accessibility, the health care insurance
plan of a province
12. (1) La condition d’accessibilité suppose
que le régime provincial d’assurance-santé :
Accessibilité
a) offre les services de santé assurés selon
des modalités uniformes et ne fasse pas obstacle, directement ou indirectement, et notamment par facturation aux assurés, à un accès satisfaisant par eux à ces services;
(a) must provide for insured health services
on uniform terms and conditions and on a
basis that does not impede or preclude, either
directly or indirectly whether by charges
made to insured persons or otherwise, reasonable access to those services by insured
persons;
b) prévoie la prise en charge des services de
santé assurés selon un tarif ou autre mode de
paiement autorisé par la loi de la province;
(b) must provide for payment for insured
health services in accordance with a tariff or
system of payment authorized by the law of
the province;
c) prévoie une rémunération raisonnable de
tous les services de santé assurés fournis par
les médecins ou les dentistes;
d) prévoie le versement de montants aux hôpitaux, y compris les hôpitaux que possède
ou gère le Canada, à l’égard du coût des services de santé assurés.
(c) must provide for reasonable compensation for all insured health services rendered
by medical practitioners or dentists; and
(d) must provide for the payment of
amounts to hospitals, including hospitals
owned or operated by Canada, in respect of
the cost of insured health services.
Reasonable
compensation
Définition de
« services de
santé assurés
facultatifs »
(2) In respect of any province in which extra-billing is not permitted, paragraph (1)(c)
shall be deemed to be complied with if the
province has chosen to enter into, and has entered into, an agreement with the medical practitioners and dentists of the province that provides
(2) Pour toute province où la surfacturation
n’est pas permise, il est réputé être satisfait à
l’alinéa (1)c) si la province a choisi de conclure
un accord et a effectivement conclu un accord
avec ses médecins et dentistes prévoyant :
Rémunération
raisonnable
a) la tenue de négociations sur la rémunération des services de santé assurés entre la
province et les organisations provinciales représentant les médecins ou dentistes qui
exercent dans la province;
(a) for negotiations relating to compensation
for insured health services between the
province and provincial organizations that
represent practising medical practitioners or
dentists in the province;
b) le règlement des différends concernant la
rémunération par, au choix des organisations
provinciales compétentes visées à l’alinéa a),
soit la conciliation soit l’arbitrage obligatoire
par un groupe représentant également les or-
(b) for the settlement of disputes relating to
compensation through, at the option of the
appropriate provincial organizations referred
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to in paragraph (a), conciliation or binding
arbitration by a panel that is equally representative of the provincial organizations and
the province and that has an independent
chairman; and
ganisations provinciales et la province et
ayant un président indépendant;
c) l’impossibilité de modifier la décision du
groupe visé à l’alinéa b), sauf par une loi de
la province.
(c) that a decision of a panel referred to in
paragraph (b) may not be altered except by
an Act of the legislature of the province.
1984, ch. 6, art. 12.
1984, c. 6, s. 12.
Conditions
CONDITIONS FOR CASH CONTRIBUTION
CONTRIBUTION PÉCUNIAIRE
ASSUJETTIE À DES CONDITIONS
13. In order that a province may qualify for
a full cash contribution referred to in section 5,
the government of the province
13. Le versement à une province de la pleine
contribution pécuniaire visée à l’article 5 est assujetti à l’obligation pour le gouvernement de
la province :
(a) shall, at the times and in the manner prescribed by the regulations, provide the Minister with such information, of a type prescribed by the regulations, as the Minister
may reasonably require for the purposes of
this Act; and
Referral to
Governor in
Council
a) de communiquer au ministre, selon les
modalités de temps et autres prévues par les
règlements, les renseignements du genre prévu aux règlements, dont celui-ci peut normalement avoir besoin pour l’application de la
présente loi;
(b) shall give recognition to the Canada
Health Transfer in any public documents, or
in any advertising or promotional material,
relating to insured health services and extended health care services in the province.
b) de faire état du Transfert dans tout document public ou toute publicité sur les services de santé assurés et les services complémentaires de santé dans la province.
R.S., 1985, c. C-6, s. 13; 1995, c. 17, s. 37; 2012, c. 19, s.
409(E).
L.R. (1985), ch. C-6, art. 13; 1995, ch. 17, art. 37; 2012, ch.
19, art. 409(A).
DEFAULTS
MANQUEMENTS
14. (1) Subject to subsection (3), where the
Minister, after consultation in accordance with
subsection (2) with the minister responsible for
health care in a province, is of the opinion that
14. (1) Sous réserve du paragraphe (3), dans
le cas où il estime, après avoir consulté conformément au paragraphe (2) son homologue
chargé de la santé dans une province :
(a) the health care insurance plan of the
province does not or has ceased to satisfy
any one of the criteria described in sections 8
to 12, or
a) soit que le régime d’assurance-santé de la
province ne satisfait pas ou plus aux conditions visées aux articles 8 à 12;
Renvoi au
gouverneur en
conseil
b) soit que la province ne s’est pas conformée aux conditions visées à l’article 13,
(b) the province has failed to comply with
any condition set out in section 13,
et que celle-ci ne s’est pas engagée de façon satisfaisante à remédier à la situation dans un délai suffisant, le ministre renvoie l’affaire au
gouverneur en conseil.
and the province has not given an undertaking
satisfactory to the Minister to remedy the default within a period that the Minister considers
reasonable, the Minister shall refer the matter
to the Governor in Council.
Consultation
process
Obligations de la
province
(2) Before referring a matter to the Governor in Council under subsection (1) in respect
of a province, the Minister shall
(2) Avant de renvoyer une affaire au gouverneur en conseil conformément au paragraphe (1) relativement à une province, le ministre :
Étapes de la
consultation
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a) envoie par courrier recommandé à son
homologue chargé de la santé dans la province un avis sur tout problème éventuel;
(a) send by registered mail to the minister
responsible for health care in the province a
notice of concern with respect to any problem foreseen;
b) tente d’obtenir de la province, par discussions bilatérales, tout renseignement additionnel disponible sur le problème et fait rapport à la province dans les quatre-vingt-dix
jours suivant l’envoi de l’avis;
(b) seek any additional information available from the province with respect to the
problem through bilateral discussions, and
make a report to the province within ninety
days after sending the notice of concern; and
c) si la province le lui demande, tient une
réunion dans un délai acceptable afin de discuter du rapport.
(c) if requested by the province, meet within
a reasonable period of time to discuss the report.
Where no
consultation can
be achieved
(3) The Minister may act without consultation under subsection (1) if the Minister is of
the opinion that a sufficient time has expired
after reasonable efforts to achieve consultation
and that consultation will not be achieved.
1984, c. 6, s. 14.
(3) Le ministre peut procéder au renvoi prévu au paragraphe (1) sans consultation préalable s’il conclut à l’impossibilité d’obtenir
cette consultation malgré des efforts sérieux déployés à cette fin au cours d’un délai convenable.
Impossibilité de
consultation
1984, ch. 6, art. 14.
Order reducing
or withholding
contribution
15. (1) Where, on the referral of a matter
under section 14, the Governor in Council is of
the opinion that the health care insurance plan
of a province does not or has ceased to satisfy
any one of the criteria described in sections 8 to
12 or that a province has failed to comply with
any condition set out in section 13, the Governor in Council may, by order,
15. (1) Si l’affaire lui est renvoyée en vertu
de l’article 14 et qu’il estime que le régime
d’assurance-santé de la province ne satisfait pas
ou plus aux conditions visées aux articles 8 à
12 ou que la province ne s’est pas conformée
aux conditions visées à l’article 13, le gouverneur en conseil peut, par décret :
Décret de
réduction ou de
retenue
a) soit ordonner, pour chaque manquement,
que la contribution pécuniaire d’un exercice
à la province soit réduite du montant qu’il
estime indiqué, compte tenu de la gravité du
manquement;
(a) direct that any cash contribution to that
province for a fiscal year be reduced, in respect of each default, by an amount that the
Governor in Council considers to be appropriate, having regard to the gravity of the default; or
b) soit, s’il l’estime indiqué, ordonner la retenue de la totalité de la contribution pécuniaire d’un exercice à la province.
(b) where the Governor in Council considers
it appropriate, direct that the whole of any
cash contribution to that province for a fiscal
year be withheld.
Amending
orders
(2) The Governor in Council may, by order,
repeal or amend any order made under subsection (1) where the Governor in Council is of the
opinion that the repeal or amendment is warranted in the circumstances.
(2) Le gouverneur en conseil peut, par décret, annuler ou modifier un décret pris en vertu
du paragraphe (1) s’il l’estime justifié dans les
circonstances.
Modification des
décrets
Notice of order
(3) A copy of each order made under this
section together with a statement of any findings on which the order was based shall be sent
forthwith by registered mail to the government
of the province concerned and the Minister
shall cause the order and statement to be laid
before each House of Parliament on any of the
(3) Le texte de chaque décret pris en vertu
du présent article de même qu’un exposé des
motifs sur lesquels il est fondé sont envoyés
sans délai par courrier recommandé au gouvernement de la province concernée; le ministre
fait déposer le texte du décret et celui de l’exposé devant chaque chambre du Parlement dans
Avis
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Commencement
of order
Reimposition of
reductions or
withholdings
When reduction
or withholding
imposed
Extra-billing
first fifteen days on which that House is sitting
after the order is made.
les quinze premiers jours de séance de celle-ci
suivant la prise du décret.
(4) An order made under subsection (1)
shall not come into force earlier than thirty
days after a copy of the order has been sent to
the government of the province concerned under subsection (3).
(4) Un décret pris en vertu du paragraphe (1)
ne peut entrer en vigueur que trente jours après
l’envoi au gouvernement de la province concernée du texte du décret aux termes du paragraphe (3).
R.S., 1985, c. C-6, s. 15; 1995, c. 17, s. 38.
L.R. (1985), ch. C-6, art. 15; 1995, ch. 17, art. 38.
16. In the case of a continuing failure to satisfy any of the criteria described in sections 8 to
12 or to comply with any condition set out in
section 13, any reduction or withholding under
section 15 of a cash contribution to a province
for a fiscal year shall be reimposed for each
succeeding fiscal year as long as the Minister is
satisfied, after consultation with the minister responsible for health care in the province, that
the default is continuing.
16. En cas de manquement continu aux
conditions visées aux articles 8 à 12 ou à l’article 13, les réductions ou retenues de la contribution pécuniaire à une province déjà appliquées pour un exercice en vertu de l’article 15
lui sont appliquées de nouveau pour chaque
exercice ultérieur où le ministre estime, après
consultation de son homologue chargé de la
santé dans la province, que le manquement se
continue.
R.S., 1985, c. C-6, s. 16; 1995, c. 17, s. 39.
L.R. (1985), ch. C-6, art. 16; 1995, ch. 17, art. 39.
17. Any reduction or withholding under section 15 or 16 of a cash contribution may be imposed in the fiscal year in which the default that
gave rise to the reduction or withholding occurred or in the following fiscal year.
17. Toute réduction ou retenue d’une contribution pécuniaire visée aux articles 15 ou 16
peut être appliquée pour l’exercice où le manquement à son origine a eu lieu ou pour l’exercice suivant.
R.S., 1985, c. C-6, s. 17; 1995, c. 17, s. 39.
L.R. (1985), ch. C-6, art. 17; 1995, ch. 17, art. 39.
EXTRA-BILLING AND USER CHARGES
SURFACTURATION ET FRAIS
MODÉRATEURS
18. In order that a province may qualify for
a full cash contribution referred to in section 5
for a fiscal year, no payments may be permitted
by the province for that fiscal year under the
health care insurance plan of the province in respect of insured health services that have been
subject to extra-billing by medical practitioners
or dentists.
18. Une province n’a droit, pour un exercice, à la pleine contribution pécuniaire visée à
l’article 5 que si, aux termes de son régime
d’assurance-santé, elle ne permet pas pour cet
exercice le versement de montants à l’égard des
services de santé assurés qui ont fait l’objet de
surfacturation par les médecins ou les dentistes.
Entrée en
vigueur du
décret
Nouvelle
application des
réductions ou
retenues
Application aux
exercices
ultérieurs
Surfacturation
1984, ch. 6, art. 18.
1984, c. 6, s. 18.
User charges
19. (1) In order that a province may qualify
for a full cash contribution referred to in section 5 for a fiscal year, user charges must not be
permitted by the province for that fiscal year
under the health care insurance plan of the
province.
19. (1) Une province n’a droit, pour un
exercice, à la pleine contribution pécuniaire visée à l’article 5 que si, aux termes de son régime d’assurance-santé, elle ne permet pour cet
exercice l’imposition d’aucuns frais modérateurs.
Frais
modérateurs
Limitation
(2) Subsection (1) does not apply in respect
of user charges for accommodation or meals
provided to an in-patient who, in the opinion of
the attending physician, requires chronic care
and is more or less permanently resident in a
hospital or other institution.
(2) Le paragraphe (1) ne s’applique pas aux
frais modérateurs imposés pour l’hébergement
ou les repas fournis à une personne hospitalisée
qui, de l’avis du médecin traitant, souffre d’une
maladie chronique et séjourne de façon plus ou
Réserve
1984, c. 6, s. 19.
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moins permanente à l’hôpital ou dans une autre
institution.
1984, ch. 6, art. 19.
Deduction for
extra-billing
20. (1) Where a province fails to comply
with the condition set out in section 18, there
shall be deducted from the cash contribution to
the province for a fiscal year an amount that the
Minister, on the basis of information provided
in accordance with the regulations, determines
to have been charged through extra-billing by
medical practitioners or dentists in the province
in that fiscal year or, where information is not
provided in accordance with the regulations, an
amount that the Minister estimates to have been
so charged.
20. (1) Dans le cas où une province ne se
conforme pas à la condition visée à l’article 18,
il est déduit de la contribution pécuniaire à
cette dernière pour un exercice un montant, déterminé par le ministre d’après les renseignements fournis conformément aux règlements,
égal au total de la surfacturation effectuée par
les médecins ou les dentistes dans la province
pendant l’exercice ou, si les renseignements
n’ont pas été fournis conformément aux règlements, un montant estimé par le ministre égal à
ce total.
Déduction en
cas de
surfacturation
Deduction for
user charges
(2) Where a province fails to comply with
the condition set out in section 19, there shall
be deducted from the cash contribution to the
province for a fiscal year an amount that the
Minister, on the basis of information provided
in accordance with the regulations, determines
to have been charged in the province in respect
of user charges to which section 19 applies in
that fiscal year or, where information is not
provided in accordance with the regulations, an
amount that the Minister estimates to have been
so charged.
(2) Dans le cas où une province ne se
conforme pas à la condition visée à l’article 19,
il est déduit de la contribution pécuniaire à
cette dernière pour un exercice un montant, déterminé par le ministre d’après les renseignements fournis conformément aux règlements,
égal au total des frais modérateurs assujettis à
l’article 19 imposés dans la province pendant
l’exercice ou, si les renseignements n’ont pas
été fournis conformément aux règlements, un
montant estimé par le ministre égal à ce total.
Déduction en
cas de frais
modérateurs
Consultation
with province
(3) The Minister shall not estimate an
amount under subsection (1) or (2) without first
undertaking to consult the minister responsible
for health care in the province concerned.
(3) Avant d’estimer un montant visé au paragraphe (1) ou (2), le ministre se charge de
consulter son homologue responsable de la santé dans la province concernée.
Consultation de
la province
Separate
accounting in
Public Accounts
(4) Any amount deducted under subsection
(1) or (2) from a cash contribution in any of the
three consecutive fiscal years the first of which
commences on April 1, 1984 shall be accounted for separately in respect of each province in
the Public Accounts for each of those fiscal
years in and after which the amount is deducted.
(4) Les montants déduits d’une contribution
pécuniaire en vertu des paragraphes (1) ou (2)
pendant les trois exercices consécutifs dont le
premier commence le 1er avril 1984 sont comptabilisés séparément pour chaque province dans
les comptes publics pour chacun de ces exercices pendant et après lequel le montant a été
déduit.
Comptabilisation
Refund to
province
(5) Where, in any of the three fiscal years
referred to in subsection (4), extra-billing or user charges have, in the opinion of the Minister,
been eliminated in a province, the total amount
deducted in respect of extra-billing or user
charges, as the case may be, shall be paid to the
province.
(5) Si, de l’avis du ministre, la surfacturation ou les frais modérateurs ont été supprimés
dans une province pendant l’un des trois exercices visés au paragraphe (4), il est versé à cette
dernière le montant total déduit à l’égard de la
surfacturation ou des frais modérateurs, selon le
cas.
Remboursement
à la province
Saving
(6) Nothing in this section restricts the power of the Governor in Council to make any order under section 15.
(6) Le présent article n’a pas pour effet de
limiter le pouvoir du gouverneur en conseil de
prendre le décret prévu à l’article 15.
Réserve
1984, c. 6, s. 20.
1984, ch. 6, art. 20.
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When deduction
made
21. Any deduction from a cash contribution
under section 20 may be made in the fiscal year
in which the matter that gave rise to the deduction occurred or in the following two fiscal
years.
21. Toute déduction d’une contribution pécuniaire visée à l’article 20 peut être appliquée
pour l’exercice où le fait à son origine a eu lieu
ou pour les deux exercices suivants.
Application aux
exercices
ultérieurs
1984, ch. 6, art. 21.
1984, c. 6, s. 21.
Regulations
REGULATIONS
RÈGLEMENTS
22. (1) Subject to this section, the Governor
in Council may make regulations for the administration of this Act and for carrying its purposes and provisions into effect, including,
without restricting the generality of the foregoing, regulations
22. (1) Sous réserve des autres dispositions
du présent article, le gouverneur en conseil
peut, par règlement, prendre toute mesure d’application de la présente loi et, notamment :
Règlements
a) définir les services visés aux alinéas a) à
d) de la définition de « services complémentaires de santé » à l’article 2;
(a) defining the services referred to in paragraphs (a) to (d) of the definition "extended
health care services" in section 2;
b) déterminer les services exclus des services hospitaliers;
(b) prescribing the services excluded from
hospital services;
c) déterminer les genres de renseignements
dont peut avoir besoin le ministre en vertu de
l’alinéa 13a) et fixer les modalités de temps
et autres de leur communication;
(c) prescribing the types of information that
the Minister may require under paragraph
13(a) and the times at which and the manner
in which that information shall be provided;
and
d) prévoir la façon dont il doit être fait état
du Transfert en vertu de l’alinéa 13b).
(d) prescribing the manner in which recognition to the Canada Health Transfer is required to be given under paragraph 13(b).
Agreement of
provinces
(2) Subject to subsection (3), no regulation
may be made under paragraph (1)(a) or (b) except with the agreement of each of the
provinces.
(2) Sous réserve du paragraphe (3), il ne
peut être pris de règlements en vertu des alinéas
(1)a) ou b) qu’avec l’accord de chaque province.
Consentement
des provinces
Exception
(3) Subsection (2) does not apply in respect
of regulations made under paragraph (1)(a) if
they are substantially the same as regulations
made under the Federal-Provincial Fiscal Arrangements Act, as it read immediately before
April 1, 1984.
(3) Le paragraphe (2) ne s’applique pas aux
règlements pris en vertu de l’alinéa (1)a) s’ils
sont sensiblement comparables aux règlements
pris en vertu de la Loi sur les arrangements fiscaux entre le gouvernement fédéral et les provinces, dans sa version précédant immédiatement le 1er avril 1984.
Exception
Consultation
with provinces
(4) No regulation may be made under paragraph (1)(c) or (d) unless the Minister has first
consulted with the ministers responsible for
health care in the provinces.
(4) Il ne peut être pris de règlements en vertu des alinéas (1)c) ou d) que si le ministre a au
préalable consulté ses homologues chargés de
la santé dans les provinces.
Consultation des
provinces
R.S., 1985, c. C-6, s. 22; 1995, c. 17, s. 40; 2012, c. 19, s.
410(E).
L.R. (1985), ch. C-6, art. 22; 1995, ch. 17, art. 40; 2012, ch.
19, art. 410(A).
REPORT TO PARLIAMENT
RAPPORT AU PARLEMENT
23. The Minister shall, as soon as possible
after the termination of each fiscal year and in
any event not later than December 31 of the
23. Au plus tard pour le 31 décembre de
chaque année, le ministre établit dans les
meilleurs délais un rapport sur l’application de
Annual report by
Minister
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
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Rapport annuel
du ministre
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Canada Health — July 8, 2012
next fiscal year, make a report respecting the
administration and operation of this Act for that
fiscal year, including all relevant information
on the extent to which provincial health care insurance plans have satisfied the criteria, and the
extent to which the provinces have satisfied the
conditions, for payment under this Act and
shall cause the report to be laid before each
House of Parliament on any of the first fifteen
days on which that House is sitting after the report is completed.
la présente loi au cours du précédent exercice,
en y incluant notamment tous les renseignements pertinents sur la mesure dans laquelle les
régimes provinciaux d’assurance-santé et les
provinces ont satisfait aux conditions d’octroi
et de versement prévues à la présente loi; le ministre fait déposer le rapport devant chaque
chambre du Parlement dans les quinze premiers
jours de séance de celle-ci suivant son achèvement.
1984, ch. 6, art. 23.
1984, c. 6, s. 23.
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CANADA
CANADA
CONSOLIDATION
CODIFICATION
Extra-billing and User
Charges Information
Regulations
Règlement concernant les
renseignements sur la
surfacturation et les frais
modérateurs
SOR/86-259
DORS/86-259
Current to November 30, 2010
À jour au 30 novembre 2010
Published by the Minister of Justice at the following address:
http://laws-lois.justice.gc.ca
Publié par le ministre de la Justice à l’adresse suivante :
http://lois-laws.justice.gc.ca
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
159
Published
consolidation is
evidence
OFFICIAL STATUS
OF CONSOLIDATIONS
CARACTÈRE OFFICIEL
DES CODIFICATIONS
Subsections 31(1) and (3) of the Legislation
Revision and Consolidation Act, in force on
June 1, 2009, provide as follows:
Les paragraphes 31(1) et (3) de la Loi sur la
révision et la codification des textes législatifs,
en vigueur le 1er juin 2009, prévoient ce qui
suit :
31. (1) Every copy of a consolidated statute or
consolidated regulation published by the Minister
under this Act in either print or electronic form is evidence of that statute or regulation and of its contents
and every copy purporting to be published by the
Minister is deemed to be so published, unless the
contrary is shown.
31. (1) Tout exemplaire d'une loi codifiée ou
d'un règlement codifié, publié par le ministre en vertu de la présente loi sur support papier ou sur support
électronique, fait foi de cette loi ou de ce règlement
et de son contenu. Tout exemplaire donné comme
publié par le ministre est réputé avoir été ainsi publié, sauf preuve contraire.
...
Inconsistencies
in regulations
160
(3) In the event of an inconsistency between a
consolidated regulation published by the Minister
under this Act and the original regulation or a subsequent amendment as registered by the Clerk of the
Privy Council under the Statutory Instruments Act,
the original regulation or amendment prevails to the
extent of the inconsistency.
Codifications
comme élément
de preuve
[...]
(3) Les dispositions du règlement d'origine avec
ses modifications subséquentes enregistrées par le
greffier du Conseil privé en vertu de la Loi sur les
textes réglementaires l'emportent sur les dispositions
incompatibles du règlement codifié publié par le ministre en vertu de la présente loi.
Incompatibilité
— règlements
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
REGULATIONS PRESCRIBING THE TYPES OF
INFORMATION THAT THE MINISTER OF
NATIONAL HEALTH AND WELFARE MAY
REQUIRE UNDER PARAGRAPH 13(A) OF THE
CANADA HEALTH ACT IN RESPECT OF
EXTRA-BILLING AND USER CHARGES AND
THE TIMES AT WHICH AND THE MANNER
IN WHICH SUCH INFORMATION SHALL BE
PROVIDED BY THE GOVERNMENT OF EACH
PROVINCE
RÈGLEMENT DÉTERMINANT LES GENRES DE
RENSEIGNEMENTS DONT PEUT AVOIR
BESOIN LE MINISTRE DE LA SANTÉ
NATIONALE ET DU BIEN-ÊTRE SOCIAL EN
VERTU DE L’ALINÉA 13A) DE LA LOI
CANADIENNE SUR LA SANTÉ QUANT À LA
SURFACTURATION
ET
AUX
FRAIS
MODÉRATEURS
ET
FIXANT
LES
MODALITÉS DE TEMPS ET LES AUTRES
MODALITÉS DE LEUR COMMUNICATION
PAR LE GOUVERNEMENT DE CHAQUE
PROVINCE
SHORT TITLE
TITRE ABRÉGÉ
1. These Regulations may be cited as the Extrabilling and User Charges Information Regulations.
1. Règlement concernant les renseignements sur la
surfacturation et les frais modérateurs.
INTERPRETATION
DÉFINITIONS
2. In these Regulations,
2. Les définitions qui suivent s’appliquent au présent
règlement.
“Act” means the Canada Health Act; (Loi)
« exercice » La période commençant le 1er avril d’une année et se terminant le 31 mars de l’année suivante. (fiscal
year)
“Minister” means the Minister of National Health and
Welfare; (ministre)
“fiscal year” means the period beginning on April 1 in
one year and ending on March 31 in the following year.
(exercice)
« Loi » La Loi canadienne sur la santé. (Act)
« ministre » Le ministre de la Santé nationale et du Bienêtre social. (Minister)
TYPES OF INFORMATION
GENRE DE RENSEIGNEMENTS
3. For the purposes of paragraph 13(a) of the Act, the
Minister may require the government of a province to
provide the Minister with information of the following
types with respect to extra-billing in the province in a
fiscal year:
3. Pour l’application de l’alinéa 13a) de la Loi, le ministre peut exiger que le gouvernement d’une province
lui fournisse les renseignements suivants sur les montants de la surfacturation pratiquée dans la province au
cours d’un exercice :
(a) an estimate of the aggregate amount that, at the
time the estimate is made, is expected to be charged
through extra-billing, including an explanation regarding the method of determination of the estimate; and
a) une estimation du montant total de la surfacturation, à la date de l’estimation, accompagnée d’une explication de la façon dont cette estimation a été obtenue;
(b) a financial statement showing the aggregate
amount actually charged through extra-billing, including an explanation regarding the method of determination of the aggregate amount.
b) un état financier indiquant le montant total de la
surfacturation effectivement imposée, accompagné
d’une explication de la façon dont cet état a été établi.
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SOR/86-259 — November 30, 2010
4. For the purposes of paragraph 13(a) of the Act, the
Minister may require the government of a province to
provide the Minister with information of the following
types with respect to user charges in the province in a
fiscal year:
4. Pour l’application de l’alinéa 13a) de la Loi, le ministre peut exiger que le gouvernement d’une province
lui fournisse les renseignements suivants sur les montants des frais modérateurs imposés dans la province au
cours d’un exercice :
(a) an estimate of the aggregate amount that, at the
time the estimate is made, is expected to be charged in
respect of user charges to which section 19 of the Act
applies, including an explanation regarding the
method of determination of the estimate; and
a) une estimation du montant total, à la date de l’estimation, des frais modérateurs visés à l’article 19 de la
Loi, accompagnée d’une explication de la façon dont
cette estimation a été obtenue;
b) un état financier indiquant le montant total des
frais modérateurs visés à l’article 19 de la Loi effectivement imposés dans la province, accompagné d’une
explication de la façon dont le bilan a été établi.
(b) a financial statement showing the aggregate
amount actually charged in respect of user charges to
which section 19 of the Act applies, including an explanation regarding the method of determination of
the aggregate amount.
TIMES AND MANNER OF FILING INFORMATION
COMMUNICATION DE RENSEIGNEMENTS
5. (1) The government of a province shall provide
the Minister with such information, of the types prescribed by sections 3 and 4, as the Minister may reasonably require, at the following times:
5. (1) Le gouvernement d’une province doit communiquer au ministre les renseignements visés aux articles
3 et 4, dont le ministre peut normalement avoir besoin,
selon l’échéancier suivant :
(a) in respect of the estimates referred to in paragraphs 3(a) and 4(a), before April 1 of the fiscal year
to which they relate; and
a) pour les estimations visées aux alinéas 3a) et 4a),
avant le 1er avril de l’exercice visé par ces estimations;
b) pour les états financiers visés aux alinéas 3b) et
4b), avant le seizième jour du vingt et unième mois
qui suit la fin de l’exercice visé par ces états.
(b) in respect of the financial statements referred to in
paragraphs 3(b) and 4(b), before the sixteenth day of
the twenty-first month following the end of the fiscal
year to which they relate.
(2) The government of a province may, at its discretion, provide the Minister with adjustments to the estimates referred to in paragraphs 3(a) and 4(a) before
February 16 of the fiscal year to which they relate.
(2) Le gouvernement d’une province peut, à sa discrétion, fournir au ministre des ajustements aux estimations prévues aux alinéas 3a) et 4a), avant le 16 février
de l’année financière visée par ces estimations.
(3) The information referred to in subsections (1) and
(2) shall be transmitted to the Minister by the most practical means of communication.
(3) Les renseignements visés aux paragraphes (1) et
(2) doivent être expédiés au ministre par le moyen de
communication le plus pratique.
2
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ANNEX B
POLICY INTERPRETATION LETTERS
There are two key policy statements that clarify the federal
position on the Canada Health Act. These statements
have been made in the form of ministerial letters from
former federal Health Ministers to their provincial and
territorial counterparts.
EPP LETTER
In June 1985, approximately one year following the passage
of the Canada Health Act in Parliament, then-federal Health
Minister Jake Epp wrote to his provincial and territorial
counterparts to set out and confirm the federal position on the
interpretation and implementation of the Canada Health Act.
Minister Epp’s letter followed several months of consultation
with his provincial and territorial counterparts. The letter
sets forth statements of federal policy intent which clarify the
criteria, conditions and regulatory provisions of the Canada
Health Act. These clarifications have been used by the federal
government in the assessment and interpretation of compliance
with the Act. The Epp letter remains an important reference for
interpretation of the Act.
FEDERAL POLICY ON
PRIVATE CLINICS
Between February 1994 and December 1994, a series of seven
federal/provincial/territorial meetings dealing wholly or in
part with private clinics took place. At issue was the growth
of private clinics providing medically necessary services
funded partially by the public system and partially by patients
and its impact on Canada’s universal, publicly funded health
care system.
At the September 1994 Federal/Provincial/Territorial Health
Ministers Meeting in Halifax, all Ministers of Health present,
with the exception of Alberta’s Health Minister, agreed to
“take whatever steps are required to regulate the development
of private clinics in Canada.”
Diane Marleau, the federal Minister of Health at the time,
wrote to all provincial and territorial Ministers of Health on
January 6, 1995 to announce the new Federal Policy on Private
Clinics. The Minister’s letter provided the federal interpretation
of the Canada Health Act as it relates to the issue of facility
fees charged directly to patients receiving medically necessary
services at private clinics. The letter stated that the definition
of “hospital” contained in the Canada Health Act, includes any
facility that provides acute, rehabilitative or chronic care. Thus,
when a provincial or territorial health insurance plan pays the
physician fee for a medically necessary service delivered at a
private clinic, it must also pay the facility fee or face a deduction
from federal transfer payments.
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[Following is the text of the letter sent on June 18, 1985 to all provincial and territorial Ministers of Health by the Honourable Jake Epp,
federal Minister of Health and Welfare. (Note: Minister Epp sent the French equivalent of this letter to Quebec on July 15, 1985.) ]
June 18, 1985
OTTAWA, K1A 0K9
Dear Minister:
Having consulted with all provincial and territorial Ministers of Health over the past several months, both individually and
at the meeting in Winnipeg on May 16 and 17, I would like to confirm for you my intentions regarding the interpretation and
implementation of the Canada Health Act. I would particularly appreciate if you could provide me with a written indication of your
views on the attached proposals for regulations in order that I may act to have these officially put in place as soon as conveniently
possible. Also, I will write to you further with regard to the material I will need to prepare the required annual report to Parliament.
As indicated at our meeting in Winnipeg, I intend to honour and respect provincial jurisdiction and authority in matters pertaining
to health and the provision of health care services. I am persuaded, by conviction and experience, that more can be achieved through
harmony and collaboration than through discord and confrontation.
With regard to the Canada Health Act, I can only conclude from our discussions that we together share a public trust and are mutually
and equally committed to the maintenance and improvement of a universal, comprehensive, accessible and portable health insurance
system, operated under public auspices for the benefit of all residents of Canada.
Our discussions have reinforced my belief that you require sufficient flexibility and administrative versatility to operate and administer
your health care insurance plans. You know far better than I ever can, the needs and priorities of your residents, in light of geographic
and economic considerations. Moreover, it is essential that provinces have the freedom to exercise their primary responsibility for the
provision of personal health care services.
At the same time, I have come away from our discussions sensing a desire to sustain a positive federal involvement and role—both
financial and otherwise—to support and assist provinces in their efforts dedicated to the fundamental objectives of the health care
system: protecting, promoting and restoring the physical and mental well-being of Canadians. As a group, provincial/territorial
Health Ministers accept a co-operative partnership with the federal government based primarily on the contributions it authorizes
for purposes of providing insured and extended health care services.
I might also say that the Canada Health Act does not respond to challenges facing the health care system. I look forward to working
collaboratively with you as we address challenges such as rapidly advancing medical technology and an aging population and strive
to develop health promotion strategies and health care delivery alternatives.
Returning to the immediate challenge of implementing the Canada Health Act, I want to set forth some reasonably comprehensive
statements of federal policy intent, beginning with each of the criteria contained in the Act.
Public Administration
This criterion is generally accepted. The intent is that the provincial health care insurance plans be administered by a public
authority, accountable to the provincial government for decision-making on benefit levels and services, and whose records and
accounts are publicly audited.
Comprehensiveness
The intent of the Canada Health Act is neither to expand nor contract the range of insured services covered under previous federal
legislation. The range of insured services encompasses medically necessary hospital care, physician services and surgical-dental
services which require a hospital for their proper performance. Hospital plans are expected to cover in-patient and out-patient
hospital services associated with the provision of acute, rehabilitative and chronic care. As regards physician services, the range of
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insured services generally encompasses medically required services rendered by licensed medical practitioners as well as surgicaldental procedures that require a hospital for proper performance. Services rendered by other health care practitioners, except those
required to provide necessary hospital services, are not subject to the Act’s criteria.
Within these broad parameters, provinces, along with medical professionals, have the prerogative and responsibility for interpreting
what physician services are medically necessary. As well, provinces determine which hospitals and hospital services are required to
provide acute, rehabilitative or chronic care.
Universality
The intent of the Canada Health Act is to ensure that all bonafide residents of all provinces be entitled to coverage and to the benefits
under one of the twelve provincial/territorial health care insurance plans. However, eligible residents do have the option not to
participate under a provincial plan should they elect to do so.
The Agreement on Eligibility and Portability provides some helpful guidelines with respect to the determination of residency status
and arrangements for obtaining and maintaining coverage. Its provisions are compatible with the Canada Health Act.
I want to say a few words about premiums. Unquestionably, provinces have the right to levy taxes and the Canada Health Act does not
infringe upon that right. A premium scheme per se is not precluded by the Act, provided that the provincial health care insurance
plan is operated and administered in a manner that does not deny coverage or preclude access to necessary hospital and physician
services to bonafide residents of a province. Administrative arrangements should be such that residents are not precluded from or
do not forego coverage by reason of an inability to pay premiums.
I am acutely aware of problems faced by some provinces in regard to tourists and visitors who may require health services while
travelling in Canada. I will be undertaking a review of the current practices and procedures with my Cabinet colleagues, the
Minister of External Affairs, and the Minister of Employment and Immigration, to ensure all reasonable means are taken to inform
prospective visitors to Canada of the need to protect themselves with adequate health insurance coverage before entering the country.
In summary, I believe all of us as Ministers of Health are committed to the objective of ensuring that all duly qualified residents
of a province obtain and retain entitlement to insured health services on uniform terms and conditions.
Portability
The intent of the portability provisions of the Canada Health Act is to provide insured persons continuing protection under their
provincial health care insurance plan when they are temporarily absent from their province of residence or when moving from
province to province. While temporarily in another province of Canada, bonafide residents should not be subject to out-of-pocket
costs or charges for necessary hospital and physician services. Providers should be assured of reasonable levels of payment in
respect of the cost of those services.
Insofar as insured services received while outside of Canada are concerned, the intent is to assure reasonable indemnification in
respect of the cost of necessary emergency hospital or physician services or for referred services not available in a province or in
neighbouring provinces. Generally speaking, payment formulae tied to what would have been paid for similar services in a province
would be acceptable for purposes of the Canada Health Act.
In my discussions with provincial/territorial Ministers, I detected a desire to achieve these portability objectives and to minimize the
difficulties that Canadians may encounter when moving or travelling about in Canada. In order that Canadians may maintain their
health insurance coverage and obtain benefits or services without undue impediment, I believe that all provincial/territorial Health
Ministers are interested in seeing these services provided more efficiently and economically.
Significant progress has been made over the past few years by way of reciprocal arrangements which contribute to the achievement
of the in-Canada portability objectives of the Canada Health Act. These arrangements do not interfere with the rights and prerogatives
of provinces to determine and provide the coverage for services rendered in another province. Likewise, they do not deter provinces
from exercising reasonable controls through prior approval mechanisms for elective procedures. I recognize that work remains to be
done respecting interprovincial payment arrangements to achieve this objective, especially as it pertains to physician services.
I appreciate that all difficulties cannot be resolved overnight and that provincial plans will require sufficient time to meet the objective
of ensuring no direct charges to patients for necessary hospital and physician services provided in other provinces.
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For necessary services provided out-of-Canada, I am confident that we can establish acceptable standards of indemnification
for essential physician and hospital services. The legislation does not define a particular formula and I would be pleased to have
your views.
In order that our efforts can progress in a coordinated manner, I would propose that the Federal-Provincial Advisory Committee
on Institutional and Medical Services be charged with examining various options and recommending arrangements to achieve the
objectives within one year.
Reasonable Accessibility
The Act is fairly clear with respect to certain aspects of accessibility. The Act seeks to discourage all point-of-service charges for
insured services provided to insured persons and to prevent adverse discrimination against any population group with respect to
charges for, or necessary use of, insured services. At the same time, the Act accents a partnership between the providers of insured
services and provincial plans, requiring that provincial plans have in place reasonable systems of payment or compensation for their
medical practitioners in order to ensure reasonable access to users. I want to emphasize my intention to respect provincial prerogatives
regarding the organization, licensing, supply, distribution of health manpower, as well as the resource allocation and priorities for
health services. I want to assure you that the reasonable access provision will not be used to intervene or interfere directly in matters
such as the physical and geographic availability of services or provincial governance of the institutions and professions that provide
insured services. Inevitably, major issues or concerns regarding access to health care services will come to my attention. I want to
assure you that my Ministry will work through and with provincial/territorial Ministers in addressing such matters.
My aim in communicating my intentions with respect to the criteria in the Canada Health Act is to allow us to work together in
developing our national health insurance scheme. Through continuing dialogue, open and willing exchange of information and
mutually understood rules of the road, I believe that we can implement the Canada Health Act without acrimony and conflict. It is
my preference that provincial/territorial Ministers themselves be given an opportunity to interpret and apply the criteria of the
Canada Health Act to their respective health care insurance plans. At the same time, I believe that all provincial/territorial Health
Ministers understand and respect my accountability to the Parliament of Canada, including an annual report on the operation of
provincial health care insurance plans with regard to these fundamental criteria.
Conditions
This leads me to the conditions related to the recognition of federal contributions and to the provision of information, both of which
may be specified in regulations. In these matters, I will be guided by the following principles:
1. to make as few regulations as possible and only if absolutely necessary;
2. to rely on the goodwill of Ministers to afford appropriate recognition of Canada’s role and contribution and to provide necessary
information voluntarily for purposes of administering the Act and reporting to Parliament;
3. to employ consultation processes and mutually beneficial information exchanges as the preferred ways and means of implementing
and administering the Canada Health Act;
4. to use existing means of exchanging information of mutual benefit to all our governments.
Regarding recognition by provincial/territorial governments of federal health contributions, I am satisfied that we can easily agree on
appropriate recognition, in the normal course of events. The best form of recognition in my view is the demonstration to the public
that as Ministers of Health we are working together in the interests of the taxpayer and patient.
In regard to information, I remain committed to maintaining and improving national data systems on a collaborative and
co-operative basis. These systems serve many purposes and provide governments, as well as other agencies, organizations, and the
general public, with essential data about our health care system and the health status of our population. I foresee a continuing,
co-operative partnership committed to maintaining and improving health information systems in such areas as morbidity, mortality,
health status, health services operations, utilization, health care costs and financing.
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I firmly believe that the federal government need not regulate these matters. Accordingly, I do not intend to use the regulatory
authority respecting information requirements under the Canada Health Act to expand, modify or change these broad-based data
systems and exchanges. In order to keep information flows related to the Canada Health Act to an economical minimum, I see only
two specific and essential information transfer mechanisms:
1. estimates and statements on extra-billing and user charges;
2. an annual provincial statement (perhaps in the form of a letter to me) to be submitted approximately six months after the
completion of each fiscal year, describing the respective provincial health care insurance plan’s operations as they relate to the
criteria and conditions of the Canada Health Act.
Concerning Item 1 above, I propose to put in place on-going regulations that are identical in content to those that have been
accepted for 1985–86. Draft regulations are attached as Annex I. To assist with the preparation of the “annual provincial statement”
referred to in Item 2 above, I have developed the general guidelines attached as Annex II. Beyond these specific exchanges, I am
confident that voluntary, mutually beneficial exchange of such subjects as Acts, regulations and program descriptions will continue.
One matter brought up in the course of our earlier meetings, is the question of whether estimates or deductions of user charges and
extra-billing should be based on “amounts charged” or “amounts collected”. The Act clearly states that deductions are to be based
on amounts charged. However, with respect to user fees, certain provincial plans appear to pay these charges indirectly on behalf of
certain individuals. Where a provincial plan demonstrates that it reimburses providers for amounts charged but not collected, say in
respect of social assistance recipients or unpaid accounts, consideration will be given to adjusting estimates/deductions accordingly.
I want to emphasize that where a provincial plan does authorize user charges, the entire scheme must be consistent with the intent
of the reasonable accessibility criterion as set forth [in this letter].
Regulations
Aside from the recognition and information regulations referred to above, the Act provides for regulations concerning hospital services
exclusions and regulations defining extended health care services.
As you know, the Act provides that there must be consultation and agreement of each and every province with respect to such
regulations. My consultations with you have brought to light few concerns with the attached draft set of Exclusions from Hospital
Services Regulations.
Likewise, I did not sense concerns with proposals for regulations defining Extended Health Care Services. These help provide greater
clarity for provinces to interpret and administer current plans and programs. They do not alter significantly or substantially those that
have been in force for eight years under Part VI of the Federal Post-Secondary Education and Health Contributions Act (1977). It may
well be, however, as we begin to examine the future challenges to health care that we should re-examine these definitions.
This letter strives to set out flexible, reasonable and clear ground rules to facilitate provincial, as much as federal, administration of
the Canada Health Act. It encompasses many complex matters including criteria interpretations, federal policy concerning conditions
and proposed regulations. I realize, of course, that a letter of this sort cannot cover every single matter of concern to every provincial
Minister of Health. Continuing dialogue and communication are essential.
In conclusion, may I express my appreciation for your assistance in bringing about what I believe is a generally accepted concurrence
of views in respect of interpretation and implementation. As I mentioned at the outset of this letter, I would appreciate an early
written indication of your views on the proposals for regulations appended to this letter. It is my intention to write to you in the near
future with regard to the voluntary information exchanges which we have discussed in relation to administering the Act and reporting
to Parliament.
Yours truly,
Jake Epp
Attachments
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[Following is the text of the letter sent on January 6, 1995 to all provincial and territorial Ministers of Health by the federal Minister
of Health, the Honourable Diane Marleau.]
January 6, 1995
Dear Minister:
RE: Canada Health Act
The Canada Health Act has been in force now for just over a decade. The principles set out in the Act (public administration, comprehensiveness, universality, portability and accessibility) continue to enjoy the support of all provincial and territorial governments. This
support is shared by the vast majority of Canadians. At a time when there is concern about the potential erosion of the publicly funded
and publicly administered health care system, it is vital to safeguard these principles.
As was evident and a concern to many of us at the recent Halifax meeting, a trend toward divergent interpretations of the Act is
developing. While I will deal with other issues at the end of this letter, my primary concern is with private clinics and facility fees.
The issue of private clinics is not new to us as Ministers of Health; it formed an important part of our discussions in Halifax last
year. For reasons I will set out below, I am convinced that the growth of a second tier of health care facilities providing medically
necessary services that operate, totally or in large part, outside the publicly funded and publicly administered system, presents a
serious threat to Canada’s health care system.
Specifically, and most immediately, I believe the facility fees charged by private clinics for medically necessary services are a major
problem which must be dealt with firmly. It is my position that such fees constitute user charges and, as such, contravene the principle
of accessibility set out in the Canada Health Act.
While there is no definition of facility fees in federal or most provincial legislation, the term, generally speaking, refers to amounts
charged for non-physician (or “hospital”) services provided at clinics and not reimbursed by the province. Where these fees are
charged for medically necessary services in clinics which receive funding for these services under a provincial health insurance plan,
they constitute a financial barrier to access. As a result, they violate the user charge provision of the Act (section 19).
Facility fees are objectionable because they impede access to medically necessary services. Moreover, when clinics which receive
public funds for medically necessary services also charge facility fees, people who can afford the fees are being directly subsidized
by all other Canadians. This subsidization of two-tier health care is unacceptable.
The formal basis for my position on facility fees is twofold. The first is a matter of policy. In the context of contemporary health care
delivery, an interpretation which permits facility fees for medically necessary services so long as the provincial health insurance plan
covers physician fees runs counter to the spirit and intent of the Act. While the appropriate pro-vision of many physician services at
one time required an overnight stay in a hospital, advances in medical technology and the trend toward providing medical services
in more accessible settings has made it possible to offer a wide range of medical procedures on an out-patient basis or outside of
full-service hospitals. The accessibility criterion in the Act, of which the user charge provision is just a specific example, was clearly
intended to ensure that Canadian residents receive all medically necessary care without financial or other barriers and regardless of
venue. It must continue to mean that as the nature of medical practice evolves.
Second, as a matter of legal interpretation, the definition of “hospital” set out in the Act includes any facility which pro-vides acute,
rehabilitative or chronic care. This definition covers those health care facilities known as “clinics”. As a matter of both policy and
legal interpretation, therefore, where a provincial plan pays the physician fee for a medically necessary service delivered at a clinic,
it must also pay for the related hospital services provided or face deductions for user charges.
I recognize that this interpretation will necessitate some changes in provinces where clinics currently charge facility fees for
medically necessary services. As I do not wish to cause undue hardship to those provinces, I will commence enforcement of this
interpretation as of October 15, 1995. This will allow the provinces the time to put into place the necessary legislative or regulatory
framework. As of October 15, 1995, I will proceed to deduct from transfer payments any amounts charged for facility fees in respect
of medically necessary services, as mandated by section 20 of the Canada Health Act. I believe this provides a reasonable transition
period, given that all provinces have been aware of my concerns with respect to private clinics for some time, and given the
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promising headway already made by the Federal/Provincial/Territorial Advisory Committee on Health Services, which has been
working for some time now on the issue of private clinics.
I want to make it clear that my intent is not to preclude the use of clinics to provide medically necessary services. I realize that
in many situations they are a cost-effective way to deliver services, often in a technologically advanced manner. However, it is my
intention to ensure that medically necessary services are provided on uniform terms and conditions, wherever they are offered.
The principles of the Canada Health Act are supple enough to accommodate the evolution of medical science and of health care
delivery. This evolution must not lead, however, to a two-tier system of health care.
I indicated earlier in this letter that, while user charges for medically necessary services are my most immediate concern, I am
also concerned about the more general issues raised by the proliferation of private clinics. In particular, I am concerned about
their potential to restrict access by Canadian residents to medically necessary services by eroding our publicly funded system.
These concerns were reflected in the policy statement which resulted from the Halifax meeting. Ministers of Health present,
with the exception of the Alberta Minister, agreed to:
take whatever steps are required to regulate the development of private clinics in Canada, and to maintain a high quality,
publicly funded medicare system.
Private clinics raise several concerns for the federal government, concerns which provinces share. These relate to:
■■ weakened public support for the tax funded and publicly administered system;
■■ the diminished ability of governments to control costs once they have shifted from the public to the private sector;
■■ the possibility, supported by the experience of other jurisdictions, that private facilities will concentrate on easy procedures,
leaving public facilities to handle more complicated, costly cases; and
■■ the ability of private facilities to offer financial incentives to health care providers that could draw them away from the public
system—resources may also be devoted to features which attract consumers, without in any way contributing to the quality of care.
The only way to deal effectively with these concerns is to regulate the operation of private clinics.
I now call on Ministers in provinces which have not already done so to introduce regulatory frameworks to govern the operation of private clinics. I would emphasize that, while my immediate concern is the elimination of user charges, it is equally important that these
regulatory frameworks be put in place to ensure reasonable access to medically necessary services and to support the viability of the
publicly funded and administered system in the future. I do not feel the implementation of such frameworks should be long delayed.
I welcome any questions you may have with respect to my position on private clinics and facility fees. My officials are willing to meet
with yours at any time to discuss these matters. I believe that our officials need to focus their attention, in the coming weeks, on the
broader concerns about private clinics referred to above.
As I mentioned at the beginning of this letter, divergent interpretations of the Canada Health Act apply to a number of other practices.
It is always my preference that matters of interpretation of the Act be resolved by finding a Federal/Provincial/Territorial consensus
consistent with its fundamental principles. I have therefore encouraged F/P/T consultations in all cases where there are disagreements.
In situations such as out-of-province or out-of-country coverage, I remain committed to following through on these consultative
processes as long as they continue to promise a satisfactory conclusion in a reasonable time.
In closing, I would like to quote Mr. Justice Emmett M. Hall. In 1980, he reminded us:
“we, as a society, are aware that the trauma of illness, the pain of surgery, the slow decline to death, are burdens enough for the
human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability.”
I trust that, mindful of these words, we will continue to work together to ensure the survival, and renewal, of what is perhaps our
finest social project.
As the issues addressed in this letter are of great concern to Canadians, I intend to make this letter publicly available once all provincial
Health Ministers have received it.
Yours sincerely,
Diane Marleau
Minister of Health
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ANNEX C
DISPUTE AVOIDANCE AND
RESOLUTION PROCESS UNDER
THE CANADA HEALTH ACT
In April 2002, the Honourable A. Anne McLellan outlined in
a letter to her provincial and territorial counterparts a Canada
Health Act Dispute Avoidance and Resolution process, which
was agreed to by provinces and territories, except Quebec. The
process meets federal and provincial/territorial interests of
avoiding disputes related to the interpretation of the principles
of the Canada Health Act, and when this is not possible,
resolving disputes in a fair, transparent and timely manner.
If these are unsuccessful, either Minister of Health involved
may refer the issues to a third party panel to undertake factfinding and provide advice and recommendations.
The process includes the dispute avoidance activities of
government-to-government information exchange; discussions
and clarification of issues, as they arise; active participation of
governments in ad hoc federal/provincial/territorial committees
on Canada Health Act issues; and Canada Health Act advance
assessments, upon request.
In September 2004, the agreement reached between the
provinces and territories in 2002 was formalized by First
Ministers, thereby reaffirming their commitment to use the
Canada Health Act Dispute Avoidance and Resolution process
to deal with Canada Health Act interpretation issues.
Where dispute avoidance activities prove unsuccessful,
dispute resolution activities may be initiated, beginning with
government-to-government fact-finding and negotiations.
The federal Minister of Health has the final authority to interpret
and enforce the Canada Health Act. In deciding whether to invoke
the non-compliance provisions of the Act, the Minister will take
the panel’s report into consideration.
On the following pages you will find the full text of Minister
McLellan’s Letter to the Honourable Gary Mar, as well as a
fact sheet on the Canada Health Act Dispute Avoidance and
Resolution Process.
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Minister of Health
Ministre de la Santé
Ottawa, Canada K1A 0K9
April 2, 2002
The Honourable Gary Mar, M.L.A.
Minister of Health and Wellness
Province of Alberta
Room 323, Legislature Building
Edmonton, Alberta
T5K 2B6
Dear Mr. Mar:
I am writing in fulfilment of my commitment to move forward on dispute avoidance and resolution as it applies to the interpretation
of the principles of the Canada Health Act.
I understand the importance provincial and territorial governments attach to having a third party provide advice and recommendations
when differences occur regarding the interpretation of the Canada Health Act. This feature has been incorporated in the approach to the
Canada Health Act Dispute Avoidance and Resolution process set out below. I believe this approach will enable us to avoid and resolve
issues related to the interpretation of the principles of the Canada Health Act in a fair, transparent and timely manner.
Dispute Avoidance
The best way to resolve a dispute is to prevent it from occurring in the first place. The federal government has rarely resorted to
penalties and only when all other efforts to resolve the issue have proven unsuccessful. Dispute avoidance has worked for us in the
past and it can serve our shared interests in the future. Therefore, it is important that governments continue to participate actively in
ad hoc federal/provincial/territorial committees on Canada Health Act issues and undertake government-to-government information
exchange, discussions and clarification on issues as they arise.
Moreover, Health Canada commits to provide advance assessments to any province or territory upon request.
Dispute Resolution
Where the dispute avoidance activities between the federal government and a provincial or territorial government prove unsuccessful,
either Minister of Health involved may initiate dispute resolution by writing to his or her counterpart. Such a letter would describe the
issue in dispute. If initiated, dispute resolution will precede any action taken under the non-compliance provisions of the Act.
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As a first step, governments involved in the dispute will, within 60 days of the date of the letter initiating the process, jointly:
■■ collect and share all relevant facts;
■■ prepare a fact-finding report;
■■ negotiate to resolve the issue in dispute; and
■■ prepare a report on how the issue was resolved.
If, however, there is no agreement on the facts, or if negotiations fail to resolve the issue, any Minister of Health involved in the
dispute may initiate the process to refer the issue to a third party panel by writing to his or her counterpart. Within 30 days of
the date of that letter, a panel will be struck. The panel will be composed of one provincial/territorial appointee and one federal
appointee who, together, will select a chairperson. The panel will assess the issue in dispute in accordance with the provisions
of the Canada Health Act, will undertake fact-finding and provide advice and recommendations. It will then report to the
governments involved on the issue within 60 days of appointment.
The Minister of Health for Canada has the final authority to interpret and enforce the Canada Health Act. In deciding whether to
invoke the non-compliance provisions of the Act, the Minister of Health for Canada will take the panel’s report into consideration.
Public Reporting
Governments will report publicly on Canada Health Act dispute avoidance and resolution activities, including any panel report.
I believe that the Government of Canada has followed through on its September 2000 Health Agreement commitments by providing
funding of $21.1 billion in the fiscal framework and by working collaboratively in other areas identified in the agreement. I expect that
provincial and territorial premiers and Health Ministers will honour their commitment to the health system accountability framework
agreed to by First Ministers in September 2000. The work of officials on performance indicators has been collaborative and effective
to date. Canadians will expect us to report on the full range of indicators by the agreed deadline of September 2002. While I am
aware that some jurisdictions may not be able to fully report on all indicators in this timeframe, public accountability is an essential
component of our effort to renew Canada’s health care system. As such, it is very important that all jurisdictions work to report on the
full range of indicators in subsequent reports.
In addition, I hope that all provincial and territorial governments will participate in and complete the joint review process agreed to
by all Premiers who signed the Social Union Framework Agreement.
The Canada Health Act Dispute Avoidance and Resolution process outlined in this letter is simple and straightforward. Should
adjustments be necessary in the future, I commit to review the process with you and other Provincial/Territorial Ministers of
Health. By using this approach, we will demonstrate to Canadians that we are committed to strengthening and preserving medicare
by preventing and resolving Canada Health Act disputes in a fair and timely manner.
Yours sincerely,
A. Anne McLellan
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FACT SHEET: CANADA HEALTH
ACT DISPUTE AVOIDANCE AND
RESOLUTION PROCESS
Scope
The provisions described apply to the interpretation of the
principles of the Canada Health Act.
Dispute Avoidance
To avoid and prevent disputes, governments will continue to:
■■ participate actively in ad hoc federal/provincial/territorial
committees on Canada Health Act issues; and
■■ undertake government-to-government information
exchange, discussions and clarification on issues as they arise.
Health Canada commits to provide advance assessments to any
province or territory upon request.
Where the dispute avoidance activities between the federal
government and a provincial or territorial government prove
unsuccessful, either Minister of Health involved may initiate
dispute resolution by writing to his or her counterpart. Such
a letter would describe the issue in dispute. If initiated,
dispute resolution will precede any action taken under
the non-compliance provisions of the Act.
As a first step, governments involved in the dispute will, within
60 days of the date of the letter initiating the process, jointly:
■■ collect and share all relevant facts;
■■ prepare a fact-finding report;
■■ negotiate to resolve the issue in dispute; and
■■ prepare a report on how the issue was resolved.
CANADA HEALTH ACT
■■ Within 30 days of the date of that letter, a panel will be struck.
The panel will be composed of one provincial/territorial
appointee and one federal appointee, who together will select
a chairperson.
■■ The panel will assess the issue in dispute in accordance
with the provisions of the Canada Health Act, will undertake
fact-finding and provide advice and recommendations.
■■ The panel will then report to the governments involved on
the issue within 60 days of appointment.
The Minister of Health for Canada has the final authority
to interpret and enforce the Canada Health Act. In deciding
whether to invoke the non-compliance provisions of the Act,
the Minister of Health for Canada will take the panel’s report
into consideration.
Public Reporting
Governments will report publicly on Canada Health Act dispute
avoidance and resolution activities, including any panel report.
Dispute Resolution
174
If however, there is no agreement on the facts, or if negotiations
fail to resolve the issue, any Minister of Health involved in
the dispute may initiate the process to refer the issue to a third
party panel by writing to his or her counterpart.
ANNUAL REPORT 2014–2015
Review
Should adjustments be necessary in the future, the Minister
of Health for Canada commits to review the process with
Provincial and Territorial Ministers of Health.
CONTACT INFORMATION FOR PROVINCIAL AND TERRITORIAL DEPARTMENTS OF HEALTH
NEWFOUNDLAND AND LABRADOR
MANITOBA
Department of Health and Community Services
Confederation Building
P.O. Box 8700
St.John’s, NL A1B 4J6
(709) 729-5021
www.gov.nl.ca/health
Manitoba Health
300 Carlton Street
Winnipeg, MB R3B 3M9
1-800-392-1207
www.manitoba.ca/health
PRINCE EDWARD ISLAND
SASKATCHEWAN
Department of Health and Wellness
P.O. Box 2000
Charlottetown, PE C1A 7N8
(902) 368-6130
www.gov.pe.ca/health
Saskatchewan Health
3475 Albert Street
Regina, SK S4S 6X6
1-800-667-7766
Email [email protected]
www.saskatchewan.ca
NOVA SCOTIA
ALBERTA
Department of Health and Wellness
1894 Barrington Street
P.O. Box 488
Halifax, NS B3J 2A8
(902) 424-5818
1-800-387-6665 (toll-free in Nova Scotia)
1-800-670-8888 (TTY/TDD)
www.novascotia.ca/DHW
Alberta Health
P.O. Box 1360, Station Main
Edmonton, AB T5J 2N3
(780) 427-7164
www.health.alberta.ca
NEW BRUNSWICK
Department of Health
P.O. Box 5100
Fredericton, NB E3B 5G8
(506) 457-4800
www.gnb.ca/health
QUEBEC
Ministry of Health and Social Services
1075 Sainte-Foy Road
Québec, QC G1S 2M1
(418) 266-7005
www.msss.gouv.qc.ca
ONTARIO
Ministry of Health and Long-Term Care
10th Floor, Hepburn Block
80 Grosvenor Street
Toronto, ON M7A 1R3
1-800-268-1153
www.health.gov.on.ca
BRITISH COLUMBIA
Ministry of Health
1515 Blanshard Street
Victoria, BC V8W 3C8
(250) 952-1742
1-800-465-4911 (toll-free in B.C.)
www.gov.bc.ca/health
YUKON
Department of Health and Social Services
Insured Health Services Branch H-2
P.O. Box 2703
Whitehorse, YT Y1A 2C6
1-867-667-5202
www.hss.gov.yk.ca
NORTHWEST TERRITORIES
Department of Health and Social Services
P.O. Box 1320
Yellowknife, NWT X1A 2L9
1-800-661-0830 or 1-867-767-9053
www.hlthss.gov.nt.ca
NUNAVUT
Department of Health
P.O. Box 1000, Station 1000
Iqaluit, NU X0A 0H0
1-867-975-5700
www.gov.nu.ca/health
Accessibility
CANADA HEALTH ACT
Public Administration
CANADA HEALTH ACT
Public Administration
Accessibility
Universality
Universality
Portability
ANNUAL REPORT 2014–2015
Comprehensiveness
Comprehensiveness
Portability
ANNUAL 2014
REPORT 2015
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