CANADA HEALTH ACT 2013–2014 ANNUAL REPORT CANAD

CANADA HEALTH ACT 2013–2014 ANNUAL REPORT CANAD
Public A dministration
A ccessibility
Univ ersality
Comprehensiv eness
Portability
CANADA HEALTH ACT
ANNUAL REPORT 2013–2014
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 2013-2014 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 2013-2014
This publication can be made available on request on diskette, large print, audio-cassette and braille.
For further information or to obtain additional copies, please contact:
Health Canada
Address Locator 0900C2
Ottawa, Ontario K1A 0K9
Telephone: (613) 957-2991
Toll free: 1-866-225-0709
Fax: (613) 941-5366
© Her Majesty the Queen in Right of Canada, represented by the Minister of Health of Canada, 2014
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 written permission of the
Minister of Public Works and Government Services Canada, Ottawa, Ontario K1A 0S5 or [email protected]
HC Pub: 140319
Cat.: H1-4/2014E-PDF
ISSN: 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___________________________________________________ 17
Newfoundland and Labrador_________________________________________________________________________________ 19
Prince Edward Island_______________________________________________________________________________________ 29
Nova Scotia______________________________________________________________________________________________ 37
New Brunswick___________________________________________________________________________________________ 47
Quebec________________________________________________________________________________________________ 57
Ontario__________________________________________________________________________________________________ 61
Manitoba________________________________________________________________________________________________ 73
Saskatchewan____________________________________________________________________________________________ 83
Alberta__________________________________________________________________________________________________ 93
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
Provincial and Territorial Departments of Health Contact Information________________________________________________ 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 five 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.
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.
The roles and responsibilities for Canada’s health care system
are shared between the federal and provincial or 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
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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 well-being
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.
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
• e xtra-billing and user charges provisions that apply only to
insured health services.
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CHAPTER 1: canada health act overview
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.
4. Portability (section 11)
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
• p ayment to hospitals to cover the cost of insured health
services.
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.
The Conditions
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 provincial and territorial governments are required to
recognize the federal financial contributions toward both insured
and extended health care services.
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1. Information (section 13(a))
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))
CHAPTER 1: canada health act overview
Extra-billing and User Charges
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.
• p rescribing which services are excluded from hospital
services;
• p rescribing 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
• p rescribing 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
Extra-billing (section 18)
Mandatory Penalty Provisions
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 surgicaldental 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. Extrabilling is seen as a barrier or impediment for people seeking
medical care, and is therefore also contrary to the accessibility
criterion.
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 extra-billing
by physicians, the federal cash contribution to that province or
territory will be reduced by that same amount.
User Charges (section 19)
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 extra-billing,
they constitute a barrier or impediment to access.
Other Elements of the Act
Regulations (section 22)
Section 22 of the Canada Health Act enables the federal
government to make regulations for administering the Act in the
following areas:
• d efining the services included in the Act’s definition of
“extended health care services,” i.e., nursing home care or
home care;
Discretionary Penalty Provisions
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 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
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CHAPTER 1: canada health act overview
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.
Excluded Persons
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 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: www.hc-sc.gc.ca/hcs-sss/medi-assur/faq-eng.php
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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.
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.
CHAPTER 1: canada health act overview
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 governmentto-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), 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.
Established Programs Financing
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.
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CHAPTER 1: canada health act overview
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 dollar-for-dollar deductions for extrabilling 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.
Canada Health and Social Transfer
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 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
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years, with an annual floor of $11 billion for the cash component
to apply until 2002-2003.
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 withholdings
pursuant to the conditions and criteria of the Act to the
Governor in Council;
• d etermining the amounts of any deductions pursuant to the
extra-billing and user charges provisions of the Act; and
• e nsuring 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.
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
CHAPTER 1: canada health act overview
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 20162017). 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 2013-2014
9
10
canada health act – annual report 2013-2014
Chapter 2
Administration and Compliance
Administration
In administering the Canada Health Act, the federal Minister of
Health is assisted by Health Canada staff at headquarters and in
the regions, and by the Department of Justice.
The Canada Health Act Division
The Canada Health Act Division at Health Canada is responsible
for administering the Act. Members of the Division located in
Ottawa and their colleagues in regional Health Canada offices
fulfill the following ongoing functions:
• m
onitoring and analysing provincial and territorial health
insurance plans for compliance with the criteria, conditions
and extra-billing and user charges provisions of the Act;
• d isseminating information on the Act and on publicly funded
health care insurance programs in Canada;
• responding to inquiries about the Act and health insurance
issues received by telephone, mail and the Internet, from the
public, members of Parliament, government departments,
stakeholder organizations and the media;
• d eveloping and maintaining formal and informal partnerships
with health officials in provincial and territorial governments
for information sharing;
• p roducing the Canada Health Act Annual Report on the
administration and operation of the Act;
• c onducting issue analysis and policy research to provide
policy advice;
• c ollaborating with provincial and territorial health department
representatives through the Interprovincial Health Insurance
Agreements Coordinating Committee (see below);
• w
orking in partnership with the provinces and territories
to investigate and resolve compliance issues and pursue
activities that encourage compliance with the Act; and
• informing the federal Minister of Health of possible noncompliance and recommending appropriate action to resolve
the issue.
Interprovincial Health Insurance Agreements
Coordinating Committee
The Canada Health Act Division chairs the Interprovincial Health
Insurance Agreements Coordinating Committee (IHIACC) and
provides a secretariat for the Committee. The Committee was
formed in 1991 to address issues affecting the interprovincial
billing of insured hospital and physician services as well as
issues related to registration and eligibility for health insurance
coverage. It oversees the application of interprovincial health
insurance agreements in accordance with the Act and serves as
a forum for discussion and information sharing as provinces and
territories develop new policies related to portability of coverage.
The within-Canada portability provisions of the Act are
implemented through a series of bilateral reciprocal billing
agreements between provinces and territories for hospital
and physician services. This generally means 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.
All provinces and territories participate in reciprocal hospital
agreements and all, with the exception of Quebec, participate in
reciprocal medical agreements. The intent of these agreements
is to ensure that Canadian residents do not face point-of-service
charges for medically required hospital and physician services
when they travel in Canada. However, these agreements are
interprovincial/territorial and are not required by the Act.
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 and regional office staff monitor
the operations of provincial and territorial health care insurance
plans in order to provide advice to the Minister on possible noncompliance with the Act. Sources for this information include:
provincial and territorial government officials and publications;
media reports; and correspondence received from the public and
other nongovernmental organizations.
canada health act – annual report 2013-2014
11
CHAPTER 2: administration and compliance
Staff in the Compliance and Interpretation Unit, 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 Act, while others may pertain to the Act 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 Canada Health Act 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/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.
However, a deduction was taken from the March 2014 Canada
Health Transfer (CHT) payment to British Columbia and a
reimbursement in the form of a positive adjustment was made to
that of Newfoundland and Labrador.
On the basis of their health ministry’s report to Health Canada,
deductions in the amount of $224,568.40 were taken from the
March 2014 CHT payments of British Columbia in respect of
extra-billing and user charges for insured health services at
private clinics in fiscal year 2011-2012.
Because Newfoundland and Labrador’s report to Health Canada
of actual extra-billing and user charges during fiscal year
2011-2012 was lower than had been previously estimated, and
penalties had already been levied, Health Canada authorised
an adjustment to increase the March 2014 CHT payments to
Newfoundland and Labrador by $10,764.56. 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.
Health Canada continues to monitor provincial and territorial
compliance with the CHA. The following key developments
occurred since the 2012-2013 Canada Health Act Annual Report
was published:
As detailed in the 2012-2013 Canada Health Act Annual Report,
in January 2011, the Vancouver General Hospital in British
Columbia began charging patients a fee when they elect to
12
canada health act – annual report 2013-2014
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 Act. For that reason, there should be no
patient charges. In May 2014, British Columbia acknowledged
Health Canada’s position and committed to respond in due
course.
In April 2012, the Westbank First Nation (WFN) announced
plans to build a private for-profit hospital on its reserve in British
Columbia to serve medical tourists and Canadians who are
willing to pay for expedited access to health care services. The
proposed health facility would raise Canada Health Act-related
concerns if insured B.C. residents were charged for publicly
insured health services provided there or gained preferential
access to those services. Health Canada communicated these
concerns to the British Columbia health ministry and continues
to seek status updates on the planned facility from the British
Columbia health ministry.
During 2013-2014, 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 Act. Typically, the fees cover a basket of uninsured services
but also promise quick access 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
indicated it would be conducting similar audits at two other clinics
and committed to share the results of all three audits with Health
Canada. The Alberta College of Physicians and Surgeons is also
examining these private primary care clinics and is considering
new or amended Standards of Practice to guide physicians
involved in these practice arrangements.
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.
Health care cooperatives are a means of increasing access
to insured health care services, sometimes in under-served
settings. Nonetheless, media reports of health care cooperatives
that charge fees as a condition of receiving insured services
raise extra-billing and user charge concerns under the
Canada Health Act. In August 2013, a working group on health
CHAPTER 2: administration and compliance
cooperatives, commissioned by the Quebec Health Minister,
released its report. At that time, the minister agreed to take
measures, including legislative amendments, to establish better
guidelines for health cooperatives to address concerns that
members were required to pay fees in order to access insured
health services. In November 2013, Health Canada received
assurance from the Quebec health ministry that it enforces the
regulations that prevent patient charges for insured services, and
that confirmed charges are reimbursed to patients who request it.
During 2013-14 there were a number of compliance and
interpretation issues, including the following, that Health Canada
continued to monitor and assess with a view to determining the
appropriate follow-up with the individuals concerned or the health
ministries of the implicated jurisdictions. Physician services
received by Quebec residents when out-of-province are not
reimbursed at host province rates, which is a requirement of the
portability criterion of the Act. Other Canadians 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 Act. 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/territory rates, which is also a requirement of the
portability criterion of the Act. Health Canada remains concerned
about patient payments for drugs administered in hospital outpatient 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 Act. 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.
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 semi-private accommodation at
no charge. In January 2014, Health Canada learned that two
hospitals are being built in Quebec that will have only semiprivate 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 Canada Health Act. British
Columbia has since corrected the problem. Ontario and Quebec
are still examining the issue.
History of Deductions and Refunds
under the Canada Health Act
The Canada Health Act, 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.
During the period 1984 to 1987, subsection 20(5) of the Act
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 Act’s initial three-year transition period, under
which refunds to provinces and territories for deductions were
possible, penalties under the Act 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 Act. 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.
canada health act – annual report 2013-2014
13
CHAPTER 2: administration and compliance
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 Canada Health
Act. 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.
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
14
canada health act – annual report 2013-2014
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.
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, $939,044 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 Canada Health Act, from April 1984 to
March 2013, deductions totaling $9,870,810 have been taken
from transfer payments in respect of the extra-billing and user
charges provisions of the Act. 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.
CHAPTER 2: administration and compliance
Deductions and refunds to CHST/CHT cash contributions in accordance with the
Canada Health Act since 1994–1995 (in dollars)
Province/
Territory
1994–1995
1995–1996
1996–1997
1997–1998
1998–1999
1999–2000
2000–2001
2001–2002
2002–2003
2003–2004
NL
0
46,000
96,000
128,000
53,000
(42,570)
0
0
0
0
PEI
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
NB
0
0
0
0
0
0
0
0
0
0
QC
0
0
0
0
0
0
0
0
0
0
ON
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
SK
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
BC
1,982,000
43,000
0
0
0
0
0
0
4,610
126,775
YK
0
0
0
0
0
0
0
0
0
0
NWT
0
0
0
0
0
0
0
0
0
0
NU
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
Total
Province/
Territory
2004–2005
2005–2006
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
Total
NL
1,100
0
0
0
0
0
3,577
58,679
50,758
(10,765)
383,779
PEI
0
0
0
0
0
0
0
0
0
0
0
NS
5,463
(8,121)
9,460
0
0
0
0
0
0
0
378,937
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
0
0
0
0
0
0
0
0
0 2,355,201
SK
0
0
0
0
0
0
0
0
0
0
AB
0
0
0
0
0
0
0
0
0
0 3,585,000
BC
72,464
29,019
114,850
42,113
66,195
73,925
75,136
33,219
280,019
224,568
3,167,893
YK
0
0
0
0
0
0
0
0
0
0
0
NWT
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
79,027
20,898
124,310
42,113
66,195
73,925
78,713
91,898
330,777
213,803
9,870,810
NU
Total
0
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.
canada health act – annual report 2013-2014
15
16
canada health act – annual report 2013-2014
Chapter 3
Provincial and Territorial Health Care
Insurance Plans in 2013-2014
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 2013-2014.
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:
• 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 chapter; and
• statistical information related to insured health services.
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. 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.
To help provinces and territories prepare their submissions to the
annual report, Health Canada provided them with the document;
Canada Health Act Annual Report 2013-2014: A Guide for
Updating Submissions (User’s Guide). This 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.
The process for the Canada Health Act Annual Report
2013-2014 was launched late spring 2014 with bilateral
teleconferences with each jurisdiction. An updated User’s Guide
was also sent to the provinces and territories at that time.
Insurance Plan Descriptions
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.
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 federal Act.
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, 2014. All
information was provided by provincial and territorial officials.
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.
canada health act – annual report 2013-2014
17
CHAPTer 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Organization of the Information
Information in the statistical tables is grouped according to the
nine subcategories described below.
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.
Registered Persons: Registered persons are the number of
residents registered with the health care insurance plans of each
province or territory.
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 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.
Insured Physician Services Provided Outside Canada:
Represents residents’ medical costs incurred while travelling
outside Canada that are paid by their home province or territory.
Insured Hospital Services Provided to Residents in Another
Province or Territory: This sub-section presents out-of-province
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.
Insured Hospital Services Provided Outside Canada: Represents
residents’ hospital costs incurred while travelling outside Canada
that are paid for by their home province or territory.
18
canada health act – annual report 2013-2014
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.
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Newfoundland and Labrador
Introduction
The majority of publicly funded health services in Newfoundland
and Labrador are delivered through four regional health
authorities (RHA). They focus on the full continuum of care,
including health promotion and protection, public health,
community services, and acute and long-term care services.
In Newfoundland and Labrador, health services are provided
to over 500,000 residents by approximately 20,000 health care
providers, support staff and administrators.
Budget 2013-14 provided almost $3 billion for health care for
Newfoundlanders and Labradorians, including over $42.5 million
to support healthy child development and to enhance child care
services for families with young children. Also included was
funding for cancer treatment enhancement programs of
$24 million. Budget 2013-2014 also included $350,000 to expand
the provincial vaccination program to provide greater access to
influenza vaccines and second dose chicken pox vaccine for
children.
1.0 Public Administration
1.1Health 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 2013-2014.
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 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.
(www.gov.nl.ca/health/publications)
The 2013-2014 Department of Health and Community Services
Annual Report was tabled in the House of Assembly on
September 12, 2014.
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
canada health act – annual report 2013-2014
19
CHAPTER 3: newfoundland and labrador
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.
For purposes of the Act, the following services are covered:
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.
• g roup immunizations or inoculations carried out by physicians
at the request of the appropriate authority; and
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.
Insured hospital services are provided for in- 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 Lieutenant-Governor in Council.
There were no services added or de-listed in 2013-2014.
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;
• M
edical Care Insurance Beneficiaries and Inquiries
Regulations; and
• Physicians and Fee Regulations.
In 2013-2014 there were 1,183 physicians registered in the
province.
20
canada health act – annual report 2013-2014
• a ll services properly and adequately provided by physicians
to beneficiaries suffering from an illness requiring medical
treatment or advice;
• d iagnostic 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 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, 2014 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.
CHAPTER 3: newfoundland and labrador
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.
• a ny 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;
Dentists may opt out of the MCP. These dentists must advise
the patient of their opted-out status, stating the fees expected,
and provide the patient with a written record of services and
fees charged. As of March 31, 2014, there were two opted-out
dentists; however, there were no associated extra billings.
• ambulance service and other forms of patient transportation;
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.
• e xaminations not necessitated by illness or at the request of a
third party except as specified by the Department;
Addition of a surgical-dental service to the list of insured services
must be approved by the Minister.
2.4Uninsured 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; nonmedically 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 non-accredited 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;
• a ny services rendered by a physician to the spouse and
children of the physician;
• a cupuncture and all procedures and services related to
acupuncture, excluding an initial assessment specifically
related to diagnosing the illness proposed to be treated by
acupuncture;
• p lastic or other surgery for purely cosmetic purposes, unless
medically indicated;
• laser treatment of telangiectasia;
• testimony in a court;
• v isits to optometrists, general practitioners and
ophthalmologists 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;
• s ex 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;
• s urgical, 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
canada health act – annual report 2013-2014
21
CHAPTER 3: newfoundland and labrador
• o ther services not within the ambit of section 3 of the Medical
Care Insurance Insured Services Regulations.
changes, they must meet the criteria for eligibility as noted above
in order to become eligible.
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.
3.2 Other Categories of Individuals
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.
3.0Universality
3.1Eligibility
There were 532,177 people registered with the Medical Care
Plan as of March 31, 2014. 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
22
canada health act – annual report 2013-2014
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
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.
4.2Coverage DuringTemporary Absences
in Canada
Newfoundland and Labrador is a party to the Interprovincial
Agreement on Eligibility and Portability regarding matters
pertaining to portability of insured services in Canada.
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.
Coverage is provided to residents during temporary absences
within Canada. The Government of Newfoundland and Labrador
has entered into formal agreements (i.e., 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.
CHAPTER 3: newfoundland and labrador
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:
• B
efore leaving the province for extended periods, a resident
must contact the MCP to obtain an out-of-province coverage
certificate.
• B
eneficiaries 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.
• S
tudents leaving the province may receive a certificate,
renewable each year, provided they submit proof of full-time
enrolment in a recognized educational institution located
outside the province.
• P
ersons leaving the province for employment purposes may
receive a certificate for coverage up to 12 months. Verification
of employment may be required.
• P
ersons must not establish residence in another province,
territory or country while maintaining coverage under the
Newfoundland MCP.
• F
or out-of-province trips of 30 days or less, an out-of-province
coverage certificate is not required, but will be issued upon
request.
• F
or out-of-province trips lasting more than 30 days, a
certificate is required as proof of a resident’s ability to pay for
services while outside the province.
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.
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.
4.3Coverage During Temporary Absences
Outside Canada
The province provides coverage to residents during temporary
absences outside Canada. Out of country insured hospital inand 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.
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 educational institutions within the province to
canada health act – annual report 2013-2014
23
CHAPTER 3: newfoundland and labrador
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 (NL) 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.
This year, Newfoundlanders and Labradorians have the
shortest wait times for radiation, bypass surgery, hip and knee
replacement and cataract surgery than any other province
in Canada according to a report released by the Wait Times
Alliance in June 2013. NL was the only province to receive A+
grades for achieving above 90 percent in the national wait time
benchmarks.
Government invested $2 million in Budget 2013 to address
endoscopy wait times and wait lists. As a result of our
partnership with CAG and the leadership of the physicians
and administration in the four RHAs, NL was the first 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 (C-GRS). The C-GRS is
a tool that enables endoscopy units to access how well they
provide patient-centered care through the completion of the
C-GRs survey self-assessment tool bi-annually. Additionally,
the department has been working with the Eastern Regional
Health Authority to complete the planning and preparatory work
in partnership with CAG to implement the Skills Enhancement in
Endoscopy (SEE) program in the province in 2014.
The Canadian Institute for Health Information’s (CIHI’s) annual
report, Wait Times for Priority Procedures in Canada, reported
that NL was the best in the country in wait time benchmarks.
The report highlighted the Orthopedic Central Intake and
Assessment Clinic in the Eastern region as an innovative
initiative that ensures referrals are spread evenly among all
orthopedic specialists so that patients avoid long waits.
Through the actions of the joint replacement strategy, NL is the
national leader with the shortest wait times in the country for hip
and knee replacement surgery. Two more Orthopedic Central
Intake and Assessment Clinics began operation in Gander
and Corner Brook in December 2013. Since NL’s strategy was
released, we have seen a 36 percent increase (from 60 to 96
24
canada health act – annual report 2013-2014
percent) in the number of knee replacement surgeries being
completed within the 182 day benchmark.
Through the actions of the Provincial Emergency Department
Wait Time Strategy, external reviews were carried out at two
additional Emergency Departments in the province. As a result
of this work, the processes for fast-tracking low acuity patients
has been improved, resulting in reductions in the time for initial
physician assessment and the number of patients leaving before
being seen.
During the fourth quarter of 2013-2014 (January 1 to March 31),
wait time reports demonstrated that, on average, 95 percent of
residents of Newfoundland and Labrador received timely access
to benchmark procedures within the recommended targets.
The national benchmark is 90 percent. Almost 100 percent of
patients received access to radiation treatment within 28 days;
100 percent of cardiac bypass patients had surgery within 148
days, which is much sooner than the benchmark of 182 days;
94 percent of first eye cataract procedures were performed
within 112 days; 96 percent of referred patients accessed hip
replacement surgery and 95 percent accessed knee replacement
surgery within 182 days.
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 regional health authorities 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,
CHAPTER 3: newfoundland and labrador
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.
6.0 Recognition 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 2013-2014, these documents include:
• the 2013-2014 Public Accounts;
• the Estimates 2013-2014, and
• the Budget Speech 2013-2014.
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 2013-2014
25
CHAPTER 3: newfoundland and labrador
Registered Persons
1. Number as of March 31st (#).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
523,433
523,508
527,714
530,521
532,177
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
51
51
51
51
51
964,078,687
1,028,697,016
1,088,392,487
1,097,535,388
1,100,291,277
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
4. Number of private for-profit facilities
providing insured health services (#).
1
1
1
1
1
5. Payments to private for-profit facilities
for insured health services ($).
432,500
660,625
697,375
845,280
916,696
Public Facilities
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 ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
1,595
1,632
1,648
1,844
1,618
16,928,930
21,096,749
17,507,684
19,988,002
21,555,451
25,770
23,156
23,482
27,681
22,461
7,325,977
7,214,089
7,216,918
8,827,387
8,118,668
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12. Total number of claims, out-patient (#).
13. Total payments, out-patient ($).
26
94
97
126
108
127
123,890
318,203
224,822
139,270
451,834
317
445
475
410
445
272,567
209,257
91,089
96,116
105,448
canada health act – annual report 2013-2014
CHAPTER 3: newfoundland and labrador
Insured Physician Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
1,075
1,096
1,115
1,155
1,183
15. Number of opted-out physicians (#).
0
0
0
0
0
16. Number of non-participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($).
not available
not available
not available
not available
not available
18. Total payments for services provided by
physicians paid through fee-for-service ($).
211,145,000
216,931,000
218,561,000
236,529,000
251,281,302
14. Number of participating physicians (#).1
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
147,000
155,000
154,000
114,000
114,000
6,991,000
6,665,000
6,627,000
6,762,000
6,954,000
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
3,100
3,600
3,400
3,400
3,300
157,000
202,000
237,000
231,000
266,000
Insured Surgical-Dental Services Within Own Province or Territory
23. Number of participating dentists (#).
24. Number of services provided (#).
25. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
31
29
25
25
26
290
1,093
2,222
2,880
1,585
158,000
329,000
455,780
203,610
28,000
2
1. Excludes inactive physicians. Total includes salaried and fee-for-service physicians.
2. Number of services and associated dollar figure low in 2009-2010 due to oral surgeon recruitment issues.
canada health act – annual report 2013-2014
27
28
canada health act – annual report 2013-2014
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Prince Edward Island
Introduction
In Prince Edward Island 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 Prince Edward Island by:
• mandating the creation of a provincial health plan;
• e stablishing mechanisms to improve patient safety and
support quality improvement processes; and
• c reating a Crown corporation (Health PEI) to oversee the
delivery of operational healthcare services.
Within this governance structure Health PEI is responsible to:
• provide, or provide for the delivery of, health services;
• operate and manage health facilities;
• m
anage 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. 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 Prince Edward Island. 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.
2.0Comprehensiveness
2.1 Insured Hospital Services
Insured hospital services are provided under the Hospital and
Diagnostic Services Insurance Act (1988). The accompanying
Regulations (1996) define the insured in- and out-patient hospital
services available at no charge to a person who is eligible.
Insured hospital services include: 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.
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
canada health act – annual report 2013-2014
29
CHAPTER 3: prince edward island
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, 2014 was 318. This
includes all physicians (complement, locums, visiting specialists,
and other non-complement physicians). Prior to 2012-2013, 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 not 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, they are required to
inform the Minister thereof and the total charge is made to the
patient for the service rendered.
As of March 31, 2014, no physicians had opted out of the
Medical Services Insurance Plan.
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- 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.
30
canada health act – annual report 2013-2014
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 U
ninsured Hospital, Physician and
Surgical-Dental Services
Provincial hospital services not covered by the Hospital Services
Insurance Plan include:
• s ervices 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;
• e xaminations required in connection with employment,
insurance, education, etc.;
• g roup examinations, immunizations or inoculations, unless
prior approval is received from Health PEI;
• p reparation 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;
• d ental services other than those procedures included as basic
health services;
• dressings, drugs, vaccines, biologicals and related materials;
• eyeglasses and special appliances;
• c hiropractic, podiatry, optometry, chiropody, osteopathy,
naturopathy, and similar treatments;
CHAPTER 3: prince edward island
• p hysiotherapy, psychology, and acupuncture except when
provided in hospital;
• reversal of sterilization procedures;
• in vitro fertilization;
• s ervices performed by another person when the supervising
physician is not present or not available;
• s ervices rendered by a physician to members of the
physician’s own household, unless approval is obtained from
Health PEI; and
• a ny other services that the Department may, upon the
recommendation of the negotiation process between the
Department, Health PEI and the Medical Society, declare noninsured.
Provincial 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 2013-2014 fiscal year.
All Island residents have equal access to services. Third parties
such as private insurers or the Workers’ Compensation Board of
Prince Edward Island do not receive priority access to services
through additional payment.
Prince Edward Island 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 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
Prince Edward Island.
All new residents must register with the Department in order to
become eligible. Persons who establish permanent residence
in Prince Edward Island 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 Prince Edward Island 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 the Department. 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 Prince Edward Island as of March 31, 204,
was 146,751.
3.2 Other Categories of Individuals
Foreign students, tourists, transients or visitors to Prince Edward
Island 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.
4.0Portability
4.1 Minimum Waiting Period
Insured persons who move to Prince Edward Island are eligible
for health insurance on the first day of the third month following
the month of arrival in the province.
canada health act – annual report 2013-2014
31
CHAPTER 3: prince edward island
4.2 Coverage During Temporary Absences
in Canada
Persons absent each year for winter vacations and similar
situations involving regular absences must reside in Prince
Edward Island 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 5(1)(e)
of the Health Services Payment Act.
The term “temporarily absent” is defined as a period of absence
from the province for up to 182 days in a 12 month period,
where the absence is for the purpose of a vacation, a visit or a
business engagement. Persons leaving the province under the
above circumstances must notify the Registration Department
before leaving.
Prince Edward Island 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
Persons must reside in Prince Edward Island 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 5(1)(e) of the Health Services Payment Act.
The Health Services Payment Act is the enabling legislation that
defines portability of health insurance during temporary absences
outside Canada, as allowed under section 5(1)(e).
Insured residents may be temporarily out of the country for a
12 month period one time only. 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 the Registration Department upon returning
from outside the country.
For Prince Edward Island 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 Prince
Edward Island rates only, in Canadian currency. Residents are
responsible for paying the difference between the full amount
charged and the amount paid by the Department.
Island residents seeking such required services may apply for
prior approval through a Prince Edward Island physician. Full
coverage may be provided for (Prince Edward Island 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 outof-country hospital or medical services not available in Canada.
5.0 Accessibility
5.1 Access to Insured Health Services
Both of Prince Edward Island’s 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.
Prince Edward Island 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.
Prince Edward Island recognizes that the health system must
constantly adapt and expand to meet the needs of our citizens.
Several examples of initiatives from the 2013-2014 fiscal year
include:
• P
EI implemented the new Catastrophic Drug Program to
provide support to any individual whose prescription drug
costs are affecting their household’s ability to maintain life
essentials.
• O
pened the new Prince Edward Home, which is a leading
edge 120-bed long-term-care facility.
• S
ignificant investments were made to improve mental health
and addiction services to provide Islanders with better access
to the care and resources they need while ensuring new
controls are put in place to help curb prescription drug abuse
in the province.
• P
EI passed the Narcotics Safety and Awareness Act which
will enable the province to monitor and analyze information
on all narcotics and other controlled substances dispensed in
Prince Edward Island.
• A
new 811 telephone service was initiated, providing Islanders
with the ability to talk with a registered nurse for health advice
24 hours per day, 7 days a week.
4.4 Prior Approval Requirement
• R
enovations to the Queen Elizabeth Hospital day surgery
department were completed. This Increased patient care
spaces, and created new post-operative care bays and a
separate and dedicated Ophthalmology surgical suite.
Prior approval is required from Health PEI before receiving
non-emergency, out-of-province medical or hospital services.
As PEI is primarily a rural province where a large segment of the
population resides outside the main service centres, local access
32
canada health act – annual report 2013-2014
CHAPTER 3: prince edward island
to health services, including acute services delivered through
community hospitals and health centres, is important to small
communities. Prince Edward Island 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.
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 growing 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 2013-2014 Annual Budget and in the 2013-2014 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 2013-2014 Annual
Report.
canada health act – annual report 2013-2014
33
CHAPTER 3: prince edward island
Registered Persons
1. Number as of March 31st (#).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
143,238
146,049
147,942
148,278
146,751
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
7
7
7
7
7
161,439,600
172,100,500
183,647,900
192,480,600
197,008,800
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
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 ($).
0
0
0
0
0
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
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 ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
2,692
2,564
2,509
2,553
2,708
26,099,326
25,159,408
23,821,199
25,941,946
25,515,954
17,147
16,763
15,391
19,351
19,692
5,385,508
5,286,499
5,136,948
6,566,417
7,616,353
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12. Total number of claims, out-patient (#).
13. Total payments, out-patient ($).
34
46
29
43
24
40
157,547
70,768
164,610
76,120
157,594
127
113
165
125
137
65,114
44,213
58,796
43,482
45,756
canada health act – annual report 2013-2014
CHAPTER 3: prince edward island
Insured Physician Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
240
242
232
344
318
15. Number of opted-out physicians (#).
0
0
0
0
0
16. Number of non-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 ($).
72,874,951
18. Total payments for services provided by
physicians paid through fee-for-service ($).
45,959,450
2
62,670,303
60,719,582
2
49,332,788
50,264,859
2
65,193,465
2
55,935,726
67,973,102
2
57,810,957
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
79,139
80,559
83,086
91,130
89,178
6,386,325
6,247,907
6,330,440
7,025,721
9,567,703
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
786
684
950
1,109
659
39,137
31,729
40,600
38,036
38,005
Insured Surgical-Dental Services Within Own Province or Territory
23. Number of participating dentists (#).
24. Number of services provided (#).
25. Total payments ($).
2009–2010
2010–2011
2011–2013
2013–2014
2014–2015
3
2
2
2
2
451
352
377
383
361
171,901
137,566
125,392
125,290
130,393
1. Prior to 2012-13, 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 have
been captured and presented since 2012-2013.
canada health act – annual report 2013-2014
35
36
canada health act – annual report 2013-2014
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Nova Scotia
Introduction
The Nova Scotia Department of Health and Wellness mission
is as follows: “providing leadership to the health system for the
delivery of care and treatment, prevention of illness and injury,
and promotion of health and healthy living.” This will further the
collaborative effort to promote and protect health, prevent illness
and injury, and reduce disparities in health status.
The Health Authorities Act established the province’s nine district
health authorities (DHAs) and their community-based supports:
community health boards (CHBs). DHAs are responsible for
governing, planning, managing, delivering and monitoring health
services within each district, and for providing planning support
to the CHBs. Services delivered by the DHAs include acute and
tertiary care, mental health, and addictions. The province is now in
the process of transitioning from nine district health authorities to
one provincial health authority which will be in place April 1, 2015.
The IWK Health Centre will remain a separate organization.
The province’s 37 CHBs develop community health plans with
primary health care and health promotion as their foundation.
DHAs draw two thirds of their board nominations from CHBs.
Their community health plans are part of the DHAs’ annual
business planning process. In addition to the nine DHAs, the
IWK Health Centre continues to have a separate board, and
administrative and service delivery structures.
The Department of Health and Wellness is responsible for
setting the strategic direction and standards for health services;
ensuring availability of quality health care; monitoring, evaluating
and reporting on performance and outcomes; and funding health
services. The Department of Health and Wellness administers
the following programs: physician and pharmaceutical services;
emergency health; continuing care; and many other insured and
publicly funded health programs and services.
Nova Scotia faces a number of challenges in the delivery of health
care services. Nova Scotia’s population is aging. Approximately
18.3 percent of the Nova Scotian population is 65 or over and this
figure is expected to reach 25.4 percent by 2026. 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 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
Two plans cover insured health services in Nova Scotia: the
Hospital Insurance and the Medical Services Insurance (MSI)
Plans.
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.
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.
canada health act – annual report 2013-2014
37
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.
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.
38
canada health act – annual report 2013-2014
Medavie Blue Cross Incorporated is responsible for providing
approximately 85 reports to the Department pertaining to
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 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.
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:
• accommodation and meals at the standard ward level;
• necessary nursing services;
• laboratory, radiological and other diagnostic procedures;
• d rugs, biologicals and related preparations, when
administered in a hospital;
CHAPTER 3: nova scotia
• routine surgical supplies;
• u se of operating room(s), case room(s) and anaesthetic
services;
• u se of radiotherapy and physiotherapy services for in-patients,
where available; and
• blood or therapeutic blood fractions.
Out-patient services include:
• laboratory and radiological examinations;
• d iagnostic procedures involving the use of radiopharmaceuticals;
• electroencephalographic examinations;
• u se of occupational and physiotherapy facilities, where
available;
• necessary nursing services;
• drugs, biologicals and related preparations;
• blood or therapeutic blood fractions;
• h ospital services in connection with most minor medical and
surgical procedures;
• day-patient diabetic care;
• s ervices 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, quality access to care. Plans are
evaluated through a centralized process by the Department of
Health and Wellness and approved by Executive Council.
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, 2014, 2,581 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, 2014, 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 noninsured 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 2013-2014. 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 to the list of insured physician
services is accomplished through a collaborative Department of
Health and Wellness, District 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 2013-2014,
26 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 2013-2014
39
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 by first approaching
the Dental Association of Nova Scotia and having them put
forward a proposal to the Department of Health and Wellness
for the addition of a new procedure. The Department of Health
and Wellness, in consultation with specific experts in the field,
renders the decision as to whether or not the new procedure
becomes an insured service.
• mileage, travel or detention time;
Insured services in the “Other extraction services” (routine
extractions) category are approved for the following groups
of patients: 1) cardiac patients, 2) transplant patients, 3)
immunocompromised patients, and 4) radiation patients. Routine
extractions for these patients will be insured 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 and not
publicly insured. It is vital to the claims approval process that the
dental treatment plans include the name of the medical specialist
providing the care and that they indicate in writing in the patient’s
medical treatment plan that the routine dental extractions are
required prior to performing the medical treatment or procedure.
• s ervices in connection with an electrocardiogram,
electromyogram or electroencephalogram, unless the
physician is a specialist in the appropriate specialty;
2.4Uninsured Hospital, Physician and
Surgical-Dental Services
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.
Uninsured hospital services include:
• preferred accommodation at the patient’s request;
• telephones;
• televisions;
• drugs and biologicals ordered after discharge from hospital;
• cosmetic surgery;
• reversal of sterilization procedures;
• surgery for sex reassignment;1
• in-vitro fertilization;
• procedures performed as part of clinical research trials;
• s ervices such as gastric bypass for morbid obesity, breast
reduction/augmentation and newborn circumcision;2 and
• s ervices not deemed medically necessary that are required by
third parties, such as insurance companies.
Uninsured physician services include:
• s ervices eligible for coverage under the Workers’
Compensation Act or under any other federal or provincial
legislation;
• telephone advice (with the exception of a pilot project
currently in place) or telephone renewal of prescriptions;
• examinations required by third parties;
• g roup immunizations or inoculations unless approved by the
Department;
• preparation of certificates or reports;
• testimony in court;
• cosmetic surgery;
• acupuncture;
• reversal of sterilization; and
• in-vitro fertilization.
Major third party agencies currently purchasing medically
necessary health services in Nova Scotia include Workers’
Compensation and the Department of National Defence.
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.
The de-insurance of insured physician services is accomplished
through a negotiation process between Doctors Nova Scotia
and the Physician Services Branch of the Department of Health
and Wellness, who jointly evaluate a procedure or process
to determine whether the services should remain an insured
benefit. If a process or procedure is deemed 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 process applies to dental and hospital services. The
last time there was any significant de-insurance of services was
in 1997.
Nova Scotia Department of Health and Wellness plans to have this insured for 2014-2015.
1
These services may be insured when approved as special consideration for medical reasons only.
2
40
canada health act – annual report 2013-2014
CHAPTER 3: nova scotia
3.0 Universality
3.2 Other Categories of Individuals
3.1 Eligibility
The following persons may also be eligible for insured health
care services in Nova Scotia once they meet the specific
eligibility criteria for their situations:
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 2013-2014, 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 2012, the exemption of RCMP members from the definition of
insured person under the Canada Health Act was removed. As a
result RCMP members are now insured persons in Nova Scotia
and have been eligible for benefits effective April 1, 2013.
In 2013-2014, the total number of residents registered with the
health insurance plan was 1,000,124.
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 2013-2014, there were 36,052 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 2013-2014, there were 2,952 individuals with Employment
Authorizations covered under the health care insurance plan.
canada health act – annual report 2013-2014
41
CHAPTER 3: nova scotia
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.
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.
In 2013-2014, there were 1,510 individuals with Student
Authorizations covered under the health care insurance plan.
4.3Coverage During Temporary Absences
Outside Canada
4.0Portability
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. Ordinarily, to be eligible for coverage, residents
must not be outside the country for more than six months in
a calendar year. In order to be covered, procedures of a nonemergency nature must have prior approval before they will be
covered by MSI.
4.1 Minimum Waiting Period
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.
4.2Coverage 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
42
canada health act – annual report 2013-2014
The total amount paid by the plan in 2013-2014 for in-patient
and out-patient hospital services received in other provinces and
territories was $31,252,104.
There were no changes made in Nova Scotia in 2013-2014
regarding in-Canada portability.
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.
There were no changes made in Nova Scotia in 2013-2014
regarding out of Canada portability. The total amount spent in
2013-2014 for insured in-patient services provided outside of
Canada was $1,242,889. 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
CHAPTER 3: nova scotia
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.
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. It is anticipated that the new structure
be in place by April 1, 2015.
Access to Insured Physician Services
Alternative funding approaches, such as block funding for group
contracts and personal services contracts, have enhanced
physician recruitment.
Access to insured physician services has also been improved
through the implementation of the CECs with improved access in
evenings and on weekends.
The province coordinates ongoing recruitment activities, and has
continued to provide funding for a re-entry program for general
practitioners wishing to enter specialty training after completing
two years of general practice service in the province.
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 and the Nova Scotia
Department of Health and Wellness. Doctors Nova Scotia is
recognized as the sole bargaining agent in support of physicians
in the province. When negotiations take place, representatives
from Doctors Nova Scotia and the Department of Health and
Wellness negotiate the total funding and other terms and
conditions. The agreement lays out what the medical services
unit value will be for physician services and addresses other
issues such as the Canadian Medical Protective Association,
membership benefits, emergency department funding, on-call
funding, dispute resolution processes, the process for specific
fee adjustments, and other process or consultation issues as
agreed to by all parties.
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 2013-2014,
approximately 24 percent of physicians were remunerated
exclusively through alternative funding. Approximately 63 percent
of physicians in Nova Scotia receive all or a portion of their
remuneration through alternative funding mechanisms.
Alternative funding can be broken down into three groups:
1)Academic Funding Plans: These are group agreements
made with clinical departments for the provision of clinical,
academic, administrative and research services from
physicians. All Academic Funding Plans are located in Halifax
at either the Queen Elizabeth II Health Sciences Centre
(QEII) or the IWK Health Centre (IWK). Most of the Academic
Specialist groups are funded through academic funding
arrangements with the exception of QEII Urology; QEII
Radiology, Obstetrics and Gynaecology; QEII Ophthalmology;
QEII Nephrology, and IWK Nephrology.
2)Alternative Payment Plans: These are agreements which
provide both clinical and administrative funding to either
individual physicians or groups of physicians who are
in practice in Nova Scotia. Currently there are standing
Alternative Payment Plans template agreements in place for
family medicine, anaesthesiology, geriatrics, neo-natology,
paediatrics, obstetrics/gynaecology, and palliative care.
3) Other Funding Programs: There are a number of other
payment programs that have been established for areas
of practice where the traditional method of fee-for-service
canada health act – annual report 2013-2014
43
CHAPTER 3: nova scotia
remuneration is not appropriate. Some examples of these
programs would be emergency department funding,
institutional psychiatry funding, 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, and follow a process similar to
physician negotiations. Dentists are paid on a fee-for-service
basis. Negotiations are underway for renewal of these services.
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 (section 20 of the Act) 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.
Section 10 of the Health Services and Insurance Act and
sections 9 through 13 of the Hospital Insurance Regulations
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canada health act – annual report 2013-2014
define the terms for payments by the Minister of Health and
Wellness to hospitals for insured hospital services.
In 2013-2014, there were 2,994 hospital beds in Nova Scotia (3.2
beds per 1,000 population). Department of Health and Wellness
direct expenditures for insured hospital services operating costs
were increased to $1,679,289,646.
6.0Recognitition Given to
Federal Transfers
In Nova Scotia, the Health Services and Insurance Act
acknowledges the federal contribution regarding the cost of
insured hospital services and insured health services provided to
provincial residents. The residents of Nova Scotia are aware of
ongoing federal contributions to Nova Scotia health care through
the Canada Health Transfer (CHT) as well as other federal funds
through press releases and media coverage.
The Government of Nova Scotia also recognized the federal
contribution under the CHT in various published documents,
including the following documents:
• Public Accounts 2013-2014 released July 31, 2014; and
• B
udget Estimates and Supplementary Detail 2012-2013
released July 31, 2014.
CHAPTER 3: nova scotia
Registered Persons
1. Number as of March 31st (#).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2013
981,922
988,585
994,018
998,763
1,000,124
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
35
35
35
35
35
1,531,561,311
1,560,236,537
1,593,552,159
1,619,915,286
1,679,289,646
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
4. Number of private for-profit facilities
providing insured health services (#).4
0
0
0
0
0
5. Payments to private for-profit facilities
for insured health services ($).
not applicable
not applicable
not applicable
not applicable
not applicable
Public Facilities
2. Number (#).
3. Payments for insured health services ($).3
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
2,089
1,946
2,402
2,259
2,034
16,289,798
13,614,172
19,417,809
19,854,352
18,363,912
39,443
38,261
36,125
39,611
39,551
11,180,204
10,978,035
12,375,773
12,272,547
12,888,192
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
not available
not available
not available
not available
not available
1,286,181
788,368
2,176,921
1,104,701
1,242,889
12. Total number of claims, out-patient (#).
not applicable
not applicable
not applicable
not applicable
not applicable
13. Total payments, out-patient ($).
not applicable
not applicable
not applicable
not applicable
not applicable
11. Total payments, in-patient ($).
3. This reflects payments made to the public facilities noted for indicator 2 above.
4. Scotia Surgery is not considered private, it is classified as a hospital (funded by the Department of Health and Wellness).
canada health act – annual report 2013-2014
45
CHAPTER 3: nova scotia
Insured Physician Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
2,401
2,434
2,473
2,507
2,581
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
17. Total payments for services provided
by physicians paid through all payment
methods ($).
637,434,810
661,968,168
681,963,292
694,184,053
712,629,560
18. Total payments for services provided by
physicians paid through fee-for-service ($).
301,217,024
301,629,014
309,391,089
310,301,903
310,882,780
14. Number of participating physicians (#).
15. Number of opted-out physicians (#).
16. Number of non-participating physicians (#).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
197,580
195,538
211,030
208,505
204,888
7,362,277
7,426,414
8,297,188
8,512,631
8,607,696
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
3,418
3,092
3,295
2,096
3,141
200,452
169,312
185,142
110,695
173,452
Insured Surgical-Dental Services Within Own Province or Territory
23. Number of participating dentists (#).
24. Number of services provided (#).5
25. Total payments ($).6
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
33
26
28
21
26
6,536
6,913
7,228
7,007
7,391
1,380,344
1,459,608
1,338,592
1,397,223
1,356,416
5. Total services includes block funded dentists.
6. Total payments does not include block funded dentists.
46
canada health act – annual report 2013-2014
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
New Brunswick
Introduction
New Brunswick continues its commitment to the five fundamental
principles of the Canada Health Act, a commitment evident both
in the day to day functioning of the various elements of the New
Brunswick health system, and in any initiatives announced or
implemented in 2013-2014.
In December 2013, the Government introduced the New
Brunswick Drug Plan. Approximately 20 percent of residents do
not have drug coverage. The Prescription and Catastrophic Drug
Insurance Act received Royal Assent on March 26, 2014 and
came into force on April 1, 2014. The plan design includes the
payment of premiums and copayments with subsidies based on
family income and size. The New Brunswick Drug Plan is being
implemented in two phases. In Phase 1, which runs from May
1, 2014 to March 31, 2015, uninsured individuals and eligible
insured individuals may voluntarily enroll. In Phase 2, which
starts April 1, 2015, it will be mandatory for all New Brunswickers
to have drug coverage. Minimum coverage standards will also
come into effect in Phase 2, which means that all private group
drug plans will be required to cover at least the drugs that are
listed on the New Brunswick Drug Plan Formulary and limits will
apply on the out-of-pocket amount that can be charged.
In 2013-2014, Department of Health spending was $45.3 million
under budget. For a system that saw consistent growth
and ballooning budgets, year after year, this was a major
achievement. A number of steps taken to find efficiencies
included:
• reducing the number of hospital-based laundries;
• implementing a cap on Medicare expenditures;
For information concerning any of the province’s health programs
and services, please visit the New Brunswick Ministry of Health
website at: http://www.gnb.ca/0051/index-e.asp.
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.
1.2 Reporting Relationship
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.
• reducing generic drug pricing to 25 percent of brand price;
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.
• linking the dispensing fees paid to pharmacies to reflect the
frequency of dispensing for various pharmaceuticals;
1.3 Audits of Accounts
• c ontinuing regional health authority administrative reductions;
and
Three groups have a mandate to audit the Medical Services
Plan.
• implementing benchmarking initiatives as identified by the
Innovation and Best Practice Council, which was established
in 2013 to promote innovation and save money by identifying
health innovation and best practices.
1)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
• c onducting a review of the financial incentives related to
recruitment;
canada health act – annual report 2013-2014
47
CHAPTER 3: new brunswick
Department. The Auditor General also conducts management
reviews on programs as he or she sees fit.
• the patient is entitled to seek services from another
practitioner who participates in the Medical Services Plan; and
2)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.
• the physician must obtain a signed waiver from the patient on
the specified form and forward the form to Medicare.
3)Monitoring and Compliance Team: This team is tasked with
managing compliance to the Medical Payment Services Act
and regulations, as well as the Negotiated Fee Schedule.
a)the medical portion of all medically required services rendered
by medical practitioners;
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, 2014 there were 1,635 participating physicians in
New Brunswick. No physicians rendering health care services
have 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;
48
canada health act – annual report 2013-2014
The services which residents are entitled to under Medicare
include:
b)certain surgical-dental procedures when performed by a
physician or a dental surgeon in a hospital.
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.
The following new service codes were added in 2013-2014:
1. Four immunization codes for flu vaccine.
2. Insertion of intracoronary stents.
3. Three codes for Radiofrequency Denervation of a facet joint.
4. Saline Sonohysterogram.
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, 2014, there were just over 100 OMSs and
dentists registered in New Brunswick. OMSs and dentists have
the same opting out provision as physicians (see section 2.2)
and must follow the same guidelines. The Department has no
CHAPTER 3: new brunswick
data for the number of non-enrolled dental practitioners in New
Brunswick.
2.4Uninsured 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.
• 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;
• s ervices provided by medical practitioners or oral and
maxillofacial surgeons to members of their immediate family;
• psychoanalysis;
• e lectrocardiogram (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;
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:
• s ervices provided within the province by medical practitioners,
oral and maxillofacial surgeons or dental practitioners for
which the fee exceeds the amount payable under regulation;
• e lective plastic surgery or other services for cosmetic
purposes;
• trans-sexual surgery;
• correction of inverted nipple;
• breast augmentation;
• otoplasty for persons over the age of eighteen;
• r emoval of minor skin lesions, except where the lesions are,
or are suspected to be, pre-cancerous;
• a bortion, unless the abortion is performed by a specialist in
the field of obstetrics and gynaecology in a hospital facility
approved by the jurisdiction in which the hospital facility is
located and two medical practitioners certify in writing that the
abortion is medically required;
• s urgical assistance for cataract surgery unless such
assistance 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;
• m
edicines, drugs, materials, surgical supplies or prosthetic
devices;
• a dvice or prescription renewal by telephone which is not
specifically provided for in the Schedule of Fees;
• e xamination of medical records or certificates at the request
of a third party, or other services required by hospital
regulations or medical by-laws;
• d ental services provided by a medical practitioner or an oral
and maxillofacial surgeon;
• s ervices that are generally accepted within New Brunswick as
experimental or that are provided as applied research;
• the fitting and supplying of eye glasses or contact lenses;
• r adiology services provided in the province by a private
radiology clinic;
• acupuncture;
• c omplete medical examinations when performed for the
purposes of periodic check-up and not for medically
necessary purposes;
• circumcision of a newborn;
• reversal of vasectomies;
• second and subsequent injections for impotence;
• reversal of tubal ligations;
• intrauterine insemination;
• b ariatric 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;
• v enipuncture 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 (i.e., fiberglass casts), provided in conjunction with
an insured health service, do not compromise reasonable access
to insured services.
• s ervices that are provided in conjunction with, or in relation to,
the services referred to above;
canada health act – annual report 2013-2014
49
CHAPTER 3: new brunswick
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 2013-2014, no services were removed from the insured
services list.
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, 2014, there were 749,613 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:
a)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.
b)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
50
canada health act – annual report 2013-2014
is required (Immigration and Citizenship documentation) and
decisions on coverage/residency are reviewed on a case-bycase basis.
Residents who were not eligible for Medicare coverage during
this reporting period included:
• regular members of the Canadian Armed Forces;
• inmates at federal institutions;
• temporary residents;
• a family member who moves from another province to New
Brunswick before other family members move;
• p ersons 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
• n on-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, signed, with 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 commonlaw relationship with or are a dependent of an eligible New
Brunswick resident and still 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.
4.2Coverage 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).
CHAPTER 3: new brunswick
Medicare coverage may be extended upon request in the case of
temporary absences to:
• s tudents in full-time attendance at an educational institution
outside New Brunswick;
• residents temporarily working in another jurisdiction; and
• r esidents whose employment requires them to travel outside
the province.
Act and regulations and the Interprovincial Agreement on
Eligibility and Portability.
The Interprovincial Agreement on Eligibility and Portability is
“within Canada” and has no bearing on the individual provinces
handling of movement outside of Canada.
Students
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.
Exceptions to this are Mobile and Contract workers.
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:
Coverage for any absence over 212 days for vacation purposes
requires the Director’s approval. This approval can only be for
up to 12 months in duration and will only be granted once every
three years.
• Medicare is contacted once every 12 months;
• p ermanent 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:
• p ermanent residency is not established outside New
Brunswick; and
• health 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.
4.3Coverage 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
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, etc.). The following
guidelines must be met to receive Mobile Worker designation:
• applications must be in writing;
• d ocumentation 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.
canada health act – annual report 2013-2014
51
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:
• p roof of enrolment must be provided from the educational
institution on an annual basis;
• Medicare must be contacted once every 12 months;
• p ermanent residency cannot be established outside New
Brunswick; and
• health coverage cannot be received elsewhere.
4.4 Prior Approval Requirement
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.
New Brunswick residents may be eligible for reimbursement
if they receive elective medical services outside the country,
provided the following requirements are met:
• 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.
52
canada health act – annual report 2013-2014
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.
Access in a resident’s official language of choice is not a limiting
factor, regardless of where a resident receives services in the
province.
5.2 Physician Compensation
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
also include a blended system.
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,
CHAPTER 3: new brunswick
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.
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.
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.
canada health act – annual report 2013-2014
53
CHAPTER 3: new brunswick
Registered Persons
1. Number as of March 31st (#).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
744,048
748,352
748,406
748,570
749,613
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
56
57
56
59
60
1,590,399,994
1,616,340,008
1,721,356,342
1,736,939,230
1,771,731,561
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
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
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
4,036
4,537
3,925
4,820
5,175
37,343,696
44,337,432
38,410,486
48,373,187
56,033,200
49,005
44,444
32,310
60,927
52,858
14,912,717
14,186,848
11,455,683
21,213,988
19,086,912
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
251
245
242
274
209
556,678
607,147
808,783
202,669
254,241
1,575
1,805
1,285
1,080
1,004
883,980
798,355
857,130
286,912
286,584
12. Total number of claims, out-patient (#).
13. Total payments, out-patient ($).
1. There are no private for-profit facilities operating in New Brunswick.
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canada health act – annual report 2013-2014
CHAPTER 3: new brunswick
Insured Physician Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
1,571
1,588
1,618
1,640
1,635
15. Number of opted-out physicians (#).
0
0
0
0
0
16. Number of non-participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($).3
505,899,089
538,111,685
543,148,047
581,432,080
554,684,438
18. Total payments for services provided by
physicians paid through fee-for-service ($).
273,030,951
279,663,511
306,092,105
307,211,084
306,411,123
14. Number of participating physicians (#). 2
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
266,918
209,868
182,746
210,727
254,378
16,206,261
11,965,539
13,221,951
15,089,061
22,127,528
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
5,885
4,610
5,072
6,425
4,714
440,957
568,937
635,020
397,912
315,078
Insured Surgical-Dental Services Within Own Province or Territory
23. Number of participating dentists (#).4
24. Number of services provided (#).
25. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
26
14
23
20
21
3,363
2,722
2,859
4,949
2,083
385,796
367,905
712,367
663,654
718,088
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, this is the number that billed the Medical Services Plan.
canada health act – annual report 2013-2014
55
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canada health act – annual report 2013-2014
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Quebec
1.0 Public Administration
1.1 Health Care Insurance Plan and Public Authority
Quebec’s hospital insurance plan, the Régime d’assurance
hospitalisation du Québec, is administered by the Ministère de la
Santé et des Services Sociaux (MSSS) (the Quebec Ministry of
Health and Social Services).
Quebec’s health insurance plan, the Régime d’assurance
maladie du Québec, is administered by the Régie de l’assurance
maladie du Québec (Régie) (the Quebec Health Insurance
Board), 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 the
government criteria for preparing reports on the planning and
performance of public authorities, including the Ministère de la
Santé et des Services Sociaux and the Régie de l’assurance
maladie du Québec.
1.3 Audit of Accounts
Both plans (the Quebec hospital insurance plan and the Quebec
health insurance plan) are operated 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,
radiology 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 are: 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 or older.
In addition to basic insured health services, the Régie also
covers the following, with some limitations, for certain residents
of Quebec, as defined by the Health Insurance Act (R.S.Q.
c. A–9), and for last-resort financial assistance recipients:
optometric services; 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 within the meaning of
the Health Insurance Act (C.Q. L.R.; c A-29) who meet the
eligibility criteria for each program, prostheses, orthotics,
orthopedic appliances, locomotion and postural aids; hearing
aids and assistive listening devices; visual aids; external breast
prostheses; ocular prostheses; permanent ostomy appliances
and compression clothing for people with lymphoedema.
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 2013-2014, 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.
Family planning services set forth by legislation and provided by
a physician are insured, as are assisted reproduction services
set forth by legislation.
canada health act – annual report 2013-2014
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CHAPTER 3: quebec
2.3 Insured Surgical-Dental Services
Services insured under this plan include maxillo-facial surgery
performed by dental surgeons and specialists in oral and maxillofacial 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 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 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 examinations, vaccinations, immunizations or
injections, 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; 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
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canada health act – annual report 2013-2014
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 providing 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.
3.0 Universality
3.1 Eligibility
Registration with the hospital insurance plan is not required.
Registration with the Régie de l’assurance maladie du Québec,
or proof of residence, 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 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 the status of resident of Quebec, 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 Ministry
of Education), persons from outside Canada who are eligible
under an agreement or accord reached 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.
CHAPTER 3: quebec
4.0 Portability
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 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 183 days or more,
but less than 12 months within a calendar year, provided such
absence occurs only once every seven years.
The costs of medical services received in another province or
territory of Canada are reimbursed at 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. 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 Témiscaming (Témiscaming 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 cooperation 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 of hospital costs in case
of emergency or sudden illness, and 75 percent reimbursement
in other cases.
As of September 1, 1996, hospital services provided outside
Canada in case of emergency or sudden illness are reimbursed
by the Régie, usually in Canadian funds, to a maximum of $100
per day if the patient was hospitalized (including in the case
of day surgery) or to a maximum of $50 per day for outpatient
services. However, haemodialysis treatments are covered to a
maximum of $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, all
medical services insured by the Régime d’assurance maladie 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 the plan in effect in that country, when the stay falls
under a social security agreement reached between the Minister
of Health and Social Services and the country in question.
canada health act – annual report 2013-2014
59
CHAPTER 3: quebec
4.4 Prior Approval Requirement
To receive full reimbursement for medical and hospital services
elsewhere in Canada or in another country, a written request
signed by two physicians with expertise in the field of the
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; attest to the
unavailability of said services in Quebec or Canada; and must
contain information about the treating physician and the address
of the facility in which the services would be provided. Following
an evaluation of the request by the Régie, authorization to
receive the services is either given or denied. Plan officials will
not give consent if the medical service in question is available in
Quebec or if it is an experimental service.
5.0 Accessibility
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 110 institutions operating as
hospital centres for a clientele suffering from acute illnesses. On
that date, 20,567 beds for persons requiring short-term care for
general or specialized ailments were allotted to these institutions.
According to the most recent available data, from April 1, 2012,
to March 31, 2013, Quebec hospital institutions had 753,480
admissions for short stays (including newborns and long-term
stays in short-term units) and 379,901 registrations for day
surgeries. These admissions accounted for 5,844,700 patient days.
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 Health and Social Services
Centres (CSSS). The centres are the result of the merger of
public institutions whose mission was to provide CLSC (local
community service centre) services, CHSLD (residential and
long-term care) services and, in most cases, neighbourhood
hospital services. CSSSs must also provide the people in their
territory with access to other medical services, 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 wellbeing of the people in that territory.
Since 2003–2004, there have been family medicine groups
(FMGs). An FMG is a group of doctors working as a team and
in close collaboration with nurses and other CSSS professionals
60
canada health act – annual report 2013-2014
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, 2014, there were 258 accredited FMGs
and 51 network-clinics in Quebec. Forty-one of the networkclinics 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 have
withdrawn from the plan and practise outside the plan, but agree
to remuneration 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 2013-2014,
the Régie paid an estimated $6.5 billion for professional
services provided to Quebec residents. Professional services
(including reimbursements to insured persons and payments to
professionals) received outside of Quebec were estimated at
$44.6 million.
5.3 Payments to Hospitals
The Minister of Health and Social Services funds hospitals
through payments directly related to the cost of insured services
provided.
The payments made in 2013-2014 to institutions operating
as hospital centres for insured health services provided to
residents of Quebec totaled nearly $11.1 billion. Payments to
hospital centres outside Quebec for hospital services totaled
approximately $212.02 million.
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Ontario
Introduction
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 $48.9 billion
(including capital) in spending for 2013-2014.
The MOHLTC provides services to the public through such
programs 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.
Fourteen Local Health Integration Networks (LHINs) plan,
fund and integrate local health care services. With the LHINs
responsible for local health care management, the MOHLTC
assumes a stewardship role by establishing overall strategic
direction and priorities for the provincial health care system.
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 Long-Term 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.
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.
LHSIA also reaffirms the requirements of the French Language
Services Act in serving Ontario’s French-speaking community.
1.2 Reporting Relationship
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.
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, more specifically, 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.1
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 Audits 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, in any given
year are included within this annual report, the last of which was
released on December 10, 2013.
MOHLTC’s accounts and transactions are published annually in
the Public Accounts of Ontario. The 2013-2014 Public Accounts
of Ontario were tabled and released on September 22, 2014.
1 E.g., long-term care homes and hospitals.
canada health act – annual report 2013-2014
61
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 2013-2014.
2.2 Insured Physician Services
Insured physician services are prescribed under the Health
Insurance Act and regulations under the Act.
Under section 11.2 of the Health Insurance Act and sub-section
37.1(1) of Regulation 552 to the Health Insurance Act, a service
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canada health act – annual report 2013-2014
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, 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 longterm 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.
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.
During 2013-2014, most physicians submitted claims for all
insured services rendered to insured persons directly to OHIP,
in accordance with section 15 of the Health Insurance Act, and
a limited number billed the insured person, as permitted by
section 15.2 of the Health Insurance Act (see also Part II of the
Commitment to the Future of Medicare Act). 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).
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.
There were approximately 28,488 physicians who submitted
claims to OHIP in 2013-2014. This figure includes physicians
submitting both fee-for-service claims and physicians included in
an alternative payment plan who submitted tracking or shadowbilled claims. In 2013-2014, there were 28 opted-out physicians
in Ontario.
In 2013-2014, there were a number of changes to the Schedule
of Benefits - Physician Services in order to implement
requirements under the 2012 Physician Services Agreement.
Changes were effective April 1, 2013 and October 1, 2013.
CHAPTER 3: ontario
2.3 Insured Surgical-Dental Services
In accordance with the Canada Health Act, certain surgicaldental services are prescribed as insured services under section
16 of 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.
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).
insured person’s request; a service that is received wholly or
partly for producing or completing a document or transmitting
information to a “third party” in prescribed circumstances; the
production or completion of a document or transmission of
information to any person other than the insured person in
prescribed circumstances; provision of a prescription when
no concomitant insured service is rendered; acupuncture
procedures; psychological testing; research and survey
programs; experimental treatment; and toll charges for longdistance telephone calls.
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.
3.0 Universality
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 for Dental Services
remains in effect. No new services were added to the Schedule
during the 2013-2014 fiscal year.
3.1 Eligibility
Regulatory changes are approved by Cabinet and generally
there is a public consultation process by way of Ontario’s
Regulatory Registry.
• h old Canadian citizenship or an immigration status as
prescribed in Regulation 552;
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
• s ubject to some limited exceptions, be physically present in
Ontario for at least 153 days in any 12-month period; and
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; the preparation or provision of a drug,
antigen, antiserum or other substance, unless the drug, antigen
or antiserum is used to facilitate a procedure or examination;
advice given by telephone at the request of the insured person
or the person’s representative; the preparation and transfer of
records when the care of the person is being transferred at the
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:
• make his or her primary place of residence in Ontario;
• 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 (i.e., 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 (i.e., those provided to federal penitentiary inmates and
Canadian Forces members).
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 Ministry review the
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denial of their OHIP eligibility by making a request in writing to
the OHIP Eligibility Review Committee. Further, 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 dental-surgical 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.
Approximately 13.4 million Ontario residents were registered
with OHIP and held valid and active health cards as of
March 31, 2014.
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, which also includes 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.
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canada health act – annual report 2013-2014
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 Ontario health insurance 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.
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 OHIP-eligible
woman who was transferred from Ontario to receive insured
health services that were pre-approved for payment by OHIP is
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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.
3.3 Premiums
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.
4.0 Portability
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, 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 threemonth waiting period in accordance with the Health Insurance
Act and its regulations 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 section 5 of 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 were insured will typically be eligible
for OHIP coverage after the last day of the second full
month following the date residency is established (i.e., 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 to 32 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 fulltime 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. Payment is at the agreed upon
in-patient rate of the plan in the province or territory where
hospitalization occurs.
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.
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CHAPTER 3: ontario
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 sections 1.7 and 1.9 through 1.14 of 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.
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
Five-year terms (specific residency requirements must be
met for 2 years between absences)
Vacation/Other
Two-year terms (specific residency requirements must be
met for 5 years between absences)
Certain family members may also qualify for continuous OHIP
coverage while accompanying the primary applicant on an
extended absence outside Canada.
Payment of out-of-country services for Ontarians who are
temporarily absent from Canada (e.g., travelling) are captured
under sections 28.1 to 28.3, 28.6, and sections 29 of Regulation
552 of the Health Insurance Act.
Out-of-Country Coverage
Out-of-country emergency hospital costs are reimbursed at
Ontario fixed per diem rates of:
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canada health act – annual report 2013-2014
• 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 out-patient renal dialysis.
During 2013-2014, emergency, medically necessary, out-ofcountry 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. Charges for medically
necessary emergency or out-of-country in-patient and out-patient
services are reimbursed only when rendered in an eligible
hospital or health facility.
4.4 Prior Approval Requirement
As set out in section 28.4 of 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. Where
the identical or equivalent service is not performed in Ontario,
or where the patient faces a delay in accessing the service
in Ontario that would result in death or medically significant
irreversible tissue damage, the patient may be entitled to full
funding for insured out-of-country health services.
The prior approval application which includes written confirmation
from the referring Ontario physician must establish that the
services or tests are:
• medically necessary;
• p erformed 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;
• g enerally accepted by the medical profession in Ontario as
appropriate for a person in the same medical circumstances
as the insured person; and either
• n ot performed in Ontario by an identical or equivalent
procedure or
• p erformed 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
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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 2013-2014 there was no formal prior approval process
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.
5.0 Accessibility
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, surgicaldental 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.
The Public Hospitals Act prohibits public hospitals in Ontario
from refusing to admit a patient if, by refusal of admission, the
patient’s life would be endangered.
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 2013-2014, 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 family health care provider (family doctor or nurse
practitioner) to find one. Insured persons without a family 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 2013-2014, MOHLTC continued to administer various
initiatives in order to improve access to health care services
across the province. Ontario has taken the initiative to maintain
an appropriate physician supply informed by evidence-based
needs, and enhance the retention and distribution of physicians
in the province by such measures as:
• s tabilizing the significant expansion in medical education
since 2003;
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CHAPTER 3: ontario
• s upporting rural and remote clinical education opportunities
for medical students;
• supporting the Northern Ontario School for Medicine;
• s upporting training and assessment programs for International
Medical Graduates and other qualified physicians who do not
meet certain requirements for practice in Ontario; and
• S
upporting 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.
• H
ealthForceOntario 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: 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.
• N
orthern 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.
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canada health act – annual report 2013-2014
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 2013-2014, 96% of General Practitioners received fee-forservice payments from OHIP, but less than 30% of them were
paid solely on a fee-for-service basis. The remaining family
physicians in Ontario receive funding through one of the primary
health models: Comprehensive Care Models (CCM), Family
Health Group (FHG), Family Health Network (FHN), Family
Health Organization (FHO), Community Health Centres, Rural
and Northern Physician Group Agreement (RNPGA), Group
Health Centre (GHC), Blended Salary Model (BSM), and
specialized agreements.
Family Health Teams (FHTs) build upon existing primary health
care physician funded models by providing funding for interdisciplinary teams of providers such as nurse practitioners,
nurses, social workers and dietitians. FHTs are located across
Ontario, in both urban and rural settings, ranging in size,
structure, scope and governance. Physicians participating in
FHTs are funded by one of three compensation options that
include: Blended Capitation (such as FHN or FHO), Complement
Based Models (RNPGA or other specialized agreements) and
BSM (for community-sponsored FHTs).
MOHLTC negotiates many elements of physician compensation
with the Ontario Medical Association (OMA). The current
Physician Services Agreement that expired on March 31, 2014
included provisions that modernized the delivery of health
care, lowered wait times through e-consultations, expanded
access to family doctors for seniors and patients with higher
needs (including an expansion of house calls), and supported
the sustainability of the health care system and the protection
of high quality patient care. The MOHLTC and the OMA are
currently engaged in negotiations of a 2014 Physician Services
Agreement. A continued theme in these current negotiations
is improved access to care; however, additional key ministry
priorities include improved quality, expansion of team-based
interdisciplinary care and increased accountability.
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5.3 Payments to Hospitals
The Ontario hospital budget system is a prospective
reimbursement system that reflects the effects of workload
increases, costs related to provincial priority services, wait time
strategies, and cost increases with respect to above-average
growth in the volume of service in specific geographic locations.
Payments are made to hospitals on a semi-monthly basis.
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 predominately global
budget system towards an activity-based 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
forefront of all health care decisions through adopting a ‘money
follows the patient’ principle. HSFR expands on Ontario’s Wait
Time Strategy funding approach to link the majority of hospitals’
funding to the types, volumes and quality of care they provide.
HSFR is a significant shift from the way Ontario hospitals are
traditionally funded, which is still largely based on historicallyderived global budgets established in 1969.
Global budgets (non-HSFR) will continue to be used for activities
that cannot be modeled or that are unique (such as forensic
mental health).
HSFR is comprised of two key components: Health Based
Allocation Model (HBAM) and Quality-Based Procedures (QBP)
funding, which will together comprise 70% (40% HBAM; 30%
QBPs) of the hospital’s total funding by 2015-2016.
Health-Based Allocation Model (HBAM): Organizational-level
funding allocated to hospitals as determined by characteristics of
the population being served. HBAM is both a funding allocation
methodology and a management tool for strategic decisionmaking. The primary objective of HBAM is to enable government
to equitably allocate funding to the Local Health Integration
Networks (LHINs) for local health services. Currently, HBAM
is designed to allocate funding for the hospital and home care
sectors. The end goal is to use HBAM to allocate funding for
other sectors as well.
Quality-Based Procedures (QBPs): 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 re-design,
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 grounded on best practices as recommended by clinical and
administrative leadership.
QBPs are an integral part of HSFR as they align funding with
quality improvement. QBPs have been identified using an
evidence-based framework that offers five perspectives for
identifying opportunity areas that have the potential for reducing
variation, leveraging best practices and existing evidence and
infrastructure, impact on transformation, improving outcomes
and safety, and improving efficiency. All five quadrants of the
framework are quality-driven and reinforce the importance of the
alignment between quality and funding.
The QBP strategy is driven by the development of best practice
recommendations from Clinical Expert Advisory Groups. Best
practice development for the QBPs is intended to promote
standardization of care by reducing unexplained variation and
ensure the patient gets the right care, at the right place and at
the appropriate time. Best practices standards will encourage
health service providers to ensure the appropriate resources are
focused on the most clinically and cost effective approaches. To
further advance QBP quality of care, the Ministry together with
experts, clinicians, administrators and other stakeholders has
developed an integrated approach to measure the quality of QBP
care. This on-going work has already resulted in a number of
QBP specific indicators that will provide benchmark information
for clinicians and administrators and as such will enable mutual
learning and promote on-going quality improvement. Also, to
evaluate the impact of the QBPs against indicators of quality, an
integrated scorecard approach has been developed.
Hospital Service Accountability Agreements: When they
assumed responsibility for their local health care systems, LHINs
negotiated two-year Hospital Service Accountability Agreements
(H-SAAs) with 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
for a fourth time to cover 2013-2014.
Public hospitals submit planning submissions to the LHINs that
are the result of broad consultations within the facilities (e.g.,
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, the
performance expected, and service levels. There are various
performance indicators that are monitored, managed and
evaluated in the agreement.
The targets and performance corridors are negotiated yearly
while taking into consideration the overall performance and
contribution of the hospital to the larger system. Where particular
indicators are outside of the performance corridor and present
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a risk, there are a number of options available to the LHIN.
Hospitals and LHINs may develop Performance Improvement
Plans to get back on track to achieving targets.
6.0 Recognition 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 2013-2014.
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canada health act – annual report 2013-2014
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Registered Persons
2009–2010
1. Number as of March 31st (#).
12,900,000
2010–2011
2
13,100,000
2011–2012
2
13,212,728
2012–2013
2
13,349,791
2013–2014
2
13,452,921
2
Insured Hospital Services Within Own Province or Territory
2009–2010
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
2010–2011
2012–2013
2013–2014
149
3
149
3
147
3
146
3
145
3
14,800,000,000
4
15,527,899,500
4
16,173,889,100
4
16,418,200,000
4
16,361,203,000
4
2009–2010
Private For-Profit Facilities
2011–2012
2010–2011
2011–2012
2012–2013
2013–2014
4. Number of private for-profit facilities
providing insured health services (#).
not available
5
not available
5
not available
5
not available
5
not available
5
5. Payments to private for-profit facilities
for insured health services ($).
not available
5
not available
5
not available
5
not available
5
not available
5
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
8,185
8,231
6,365
7,019
6,924
64,688,077
68,384,505
46,960,837
58,107,802
60,733,276
138,594
130,855
116,541
130,058
133,429
36,399,952
35,431,819
33,598,383
37,866,652
41,057,654
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
28,223
28,420
30,348
29,616
26,354
91,456,638
52,706,316
42,559,353
43,824,878
45,624,997
12. Total number of claims, out-patient (#).
not available
6
not available
6
not available
6
not available
6
not available
6
13. Total payments, out-patient ($).
not available
7
not available
7
not available
7
not available
7
not available
7
2. These estimates represent the number of Valid and Active Health Cards (have current eligibility and resident has incurred a claim in the last 7 years).
3. Number represents all publicly-funded hospitals excluding specialty psychiatric hospitals. Specialty psychiatric hospitals are excluded in order to conform to CHAAR reporting guide.
4. Amount represents funding for all public hospitals excluding specialty psychiatric hospitals.
5. Data are not collected in a single system in MOHLTC. Further, the MOHLTC is unable to categorize providers/facilities as “for-profit” as MOHLTC does not have financial statements
detailing service providers’ disbursement of revenues from the Ministry.
6. Included in #10.
7. Included in #11.
canada health act – annual report 2013-2014
71
CHAPTER 3: ontario
Insured Physician Services Within Own Province or Territory
14. Number of participating physicians (#).
15. Number of opted-out physicians (#).
16. Number of non-participating physicians (#).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
25,166
25,995
26,818
27,242
28,488
35
34
32
29
28
0
8
0
8
0
8
0
8
0
8
17. Total payments for services provided
by physicians paid through all payment
methods ($).
9,727,123,611
9
10,374,311,208
9
11,008,532,900
9
11,228,719,988
9
11,379,311,227
9
18. Total payments for services provided by
physicians paid through fee-for-service ($).
6,812,333,798
7,052,261,365
7,508,636,523
7,402,377,170
7,600,334,259
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
596,430
723,766
536,447
553,823
672,661
26,204,597
25,237,480
25,252,852
26,017,930
30,248,528
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
216,715
213,717
234,420
214,080
192,773
41,652,064
12,455,597
7,922,281
6,537,845
5,844,999
Insured Surgical-Dental Services Within Own Province or Territory
23. Number of participating dentists (#).
24. Number of services provided (#).
25. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
277
282
262
273
275
99,427
96,797
96,735
93,672
95,810
14,324,505
13,525,890
13,532,519
12,525,404
12,713,974
8. Ontario has no non-participating physicians, only opted-out physicians who are reported under item #15.
9. 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 2009-2010, 2010-2011, 2011-2012, and 2012-2013 have been updated to agree with Public Accounts.
— Fiscal Year 2013-2014 is based on Interim (Unpublished) Public Accounts.
72
canada health act – annual report 2013-2014
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Manitoba
Introduction
• E
xpanded the number of Students Working Against Tobacco
(SWAT) teams to 50 in Manitoba schools.
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.
• E
xpanded the Electronic Medical Record (EMR) Repository
by adding additional clinics. Currently well over 100 primary
care clinics regularly submit EMR data.
MHHLS remains committed to the principles of Medicare and
improving the health status of all Manitobans. In 2013-2014
Manitoba continued to support these commitments through the
activities described below:
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.
• C
ontinued to increase access to health care teams and
supports within the Family Doctor for Every Manitoban by
2015 initiative.
• C
ontinued to implement the Cancer Wait Time Strategy
entitled, Transforming the Cancer Patient Journey in
Manitoba, and established the Cancer HelpLine in Winnipeg.
• L aunched Advancing Continuing Care—A Blueprint to
Support System Change, which outlines priority actions to
further ensure that appropriate local support services match
the needs of individuals and families along the continuum,
including high quality, dignified end-of-life care.
• C
ommenced the Healthy Workplaces Campaign: Wellness
Works. Great staff. Great workplaces. Great results.
• Initiated the Nurse Practitioner Education Grant.
• P
rovided Lean Six Sigma Green and Black Belt quality
improvement training to 48 health care staff, adding over
$4.2 million in reinvestment and over 362,000 fewer patient
wait days. Total reinvested savings for the Lean Six Sigma
initiative now exceeds $11 million.
• W
ith the assistance of the Addictions Foundation of Manitoba,
established a Knowledge Exchange Centre with emphasis
on sharing information on evidence-based practices in
addictions.
• R
eached the milestone of 100 Age Friendly communities in
Manitoba.
• C
ompleted the go-live phase of the Drug Program Information
Network Infrastructure Renewal Project, with approximately
350 pharmacy sites.
1.0 Public Administration
1.1 Health Care Insurance Plan and Public Authority
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 2013-2014 fiscal year that affected the public
administration of the MHSIP.
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
canada health act – annual report 2013-2014
73
CHAPTER 3: manitoba
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.
The number of medical practitioners registered with Manitoba
Health, Healthy Living and Seniors (MHHLS) to provide insured
services as of March 31, 2014 was 2,635, of these 2,354 are
participating.
1.3 Audits of Accounts
A physician, by giving notice to the Minister in writing, may elect
to collect the fees for medical services rendered to insured
persons other than from the Minister, 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.
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 2013-2014 fiscal
year and is contained in the Manitoba Health Annual Report,
2013-2014. 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, 2014, there were 96 facilities providing insured
hospital services to both in- 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- and outpatient 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.
All hospital services are added to the list of available hospital
services through the health planning process. 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.
74
canada health act – annual report 2013-2014
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 2013-2014.
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 2013-2014, a number of new insured services
were added to a revised fee schedule. The Physician’s Manual 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 (DMb).
The DMb will negotiate the item, including the fee, with MHHLS.
MHHLS may also initiate this process.
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
CHAPTER 3: manitoba
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 2013-2014.
3.0Universality
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.
The Health Services Insurance Act defines the eligibility of
Manitoba residents for coverage under the provincial health care
insurance plan.
2.4Uninsured 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.
The Hospital Services Insurance and Administration 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 MHHLS monitor
compliance.
All Manitoba residents have equal 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 2013-2014.
3.1Eligibility
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.
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
canada health act – annual report 2013-2014
75
CHAPTER 3: manitoba
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 ninedigit Personal Health Identification Number (PHIN) is used for
payment of all hospital services and for the provincial
drug program.
As of March 31, 2014, there were 1,289,268 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, subsection 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
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.
76
canada health act – annual report 2013-2014
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.
4.2Coverage 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.
4.3Coverage During Temporary Absences
Outside Canada
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.
Section 7(1)(g) of the Residency and Registration Regulation
extends the period during which a person who is 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
CHAPTER 3: manitoba
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.
5.0Accessibility
5.1 Access to Insured Health Services
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.
to have access to a family physician will have such access by
2015. To achieve this goal, Manitoba invested in new initiatives
including Primary Care Networks (including teams), opened a
fourth Quick Care Clinic, launched two mobile clinics, one in
the Prairie-Mountain Regional Health Authority (RHA) and the
other in the Southern 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 pilot
(a network of general practitioners linked to patients through
the 24-hour Health Links-Info Santé service). Since 2008,
MHHLS funded and coordinated over 60 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.
In 2013, MHHLS redeveloped the Family Doctor Connection
Program, a program by which Manitobans can 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. Data gathering and analysis has been
improved, to enable a greater understanding of geographic areas
that require improved provider supply to support planning to
address capacity.
The Cancer Patient Journey initiative was established in 2011 to
streamline cancer services and significantly reduce the wait time
for patients between the time cancer is suspected and the start
of effective treatment to 60 days or less. Key initiative activities
to date include:
• In 2013, 20 rapid improvement events within 15 sites
throughout Manitoba by the Lean Six Sigma trained Rapid
Improvement Leads. These improvement events resulted in a
reduction of 18 patient wait days from suspicion to treatment
for breast cancer patients.
• that no charges can be made to individuals who receive
insured surgical services, or to anyone else on that person’s
behalf; and
• O
pening of the Regional Cancer Program Hubs located in
the Prairie Mountain Health Region and Interlake-Eastern
Regional Health Authority. These Cancer Hubs are rural
oncology outpatient 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 living
outside of Winnipeg.
• that a surgical facility cannot perform procedures requiring
overnight stays and thereby function as a private hospital.
Under Manitoba’s Cancer Strategy 2012-2017 the following
activities were implemented:
MHHLS continues to invest in improving clients’ access. In 2010,
Manitoba made a commitment that all Manitobans who wish
• O
pening of an Urgent Care Clinic and Helpline in December
2013 at CancerCare Manitoba (CCMB) to provide after-
The Health Services Insurance Act, the Private Hospitals Act
and the Hospitals Act include definitions and other provisions to
ensure:
canada health act – annual report 2013-2014
77
CHAPTER 3: manitoba
hours support to Manitobans facing cancer. The Urgent Care
Clinic is open weekdays and evenings to assist patients with
cancer-related complications and side-effects 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.
• E
stablishment of Lynch Syndrome testing at Diagnostic
Services of Manitoba (DSM), in February 2014, to help
identify patients at a greater risk for inherited colo-rectal
cancer. Lynch Syndrome is a disorder that significantly
increases the risk of developing colo-rectal cancer. As a
result of this testing, patients have access to increased
cancer surveillance which could lead to earlier detection and
improved cancer survival rates. Immediate family members
of affected patients will also benefit from this new testing, as
it will help to identify their risk of developing cancer and allow
them to consider prevention and early detection measures.
Other improvements in Cancer and Diagnostic care include:
• R
eplacement of the computed radiography facilities in
Thompson, Gillam and Lynn Lake in May 2013. This new
equipment creates 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.
• R
edesign of the DSM building space at the Glenboro Health
Centre in July 2013, which included installation of new x-ray
equipment and renovation to the waiting room and reception
areas.
• Installation of a new robotic intravenous automation machine
(RIVA) at CCMB in November 2013. RIVA is a fully automated
system that mixes intravenous (IV) chemotherapy drugs that
are regularly used and very repetitious. The use of RIVA has
resulted in improvements in the safety and accuracy of the IV
chemotherapy mixtures and also allows CCMB to track drug
lot numbers and expiry dates, which is a new Health Canada
requirement for pediatrics.
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 17,795 active practicing nurses
in Manitoba in 2013. This represents a net gain of 143 nurses
over 2012 (17,652). The number of active practical nurses in
Manitoba provided in the 2012-2013 Annual Report (17,578
practicing nurses) reflected an anomaly in the information
reported by the College of Registered Nurses of Manitoba and
the College of Licensed Practical Nurses of Manitoba. The total
78
canada health act – annual report 2013-2014
of the corrected figures provided by the Colleges for 2012 is
17,652 practicing.
The Nurses Recruitment and Retention Fund contributes
significantly to improving the nursing supply in Manitoba.
Extended Practice Regulations allow nurses on the register to
independently prescribe drugs, order screening and diagnostic
tests, and perform minor surgical and invasive procedures. The
number of nurses on the Extended Practice register has grown
from four in 2005 to 131 in 2013.
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 September 2014, there were 62 PAs
registered with the CPSM.
5.2 Physician Compensation
Manitoba continues to offer 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 2013-2014 fiscal year.
Fee-for-service remains the dominant 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
compensation through mechanisms other than fee-for-service,
including through a salary (employment relationship) or those
who work on an independent contract basis. Manitoba also
uses blended payment methods to adjust fee-for-service income
that may not be adequate to compensate for all services
rendered by the physician. As well, physicians may receive
CHAPTER 3: manitoba
sessional payments for providing medical services on a timebased arrangement, as well as stipends for on-call and other
responsibilities.
Manitoba Health, Healthy Living and Seniors represents
Manitoba in negotiations with physicians. Most physicians are
represented by Doctors Manitoba with some notable exceptions,
such as oncologists.
The current Master Agreement between Doctors Manitoba and
Manitoba is in effect from April 1, 2011 to March 31, 2015.
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 the regional health authorities’ 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.
The Physician’s Manual, a billing and fee guide, provides
Manitoba physicians with a listing of medical services that
are insured by MHHLS. Five main system data checks and
processes within the MHHLS mainframe system ensure that
claims for insured services are processed in accordance with the
Rules of Application in the Physician’s Manual under the Health
Services Insurance Act. Appeals under the Physician’s Manual
are heard by a grievance panel. In addition, the Manitoba Health
Appeal Board, a quasi-judicial tribunal, hears appeals if a person
is not satisfied with certain decisions of MHHLS or is denied
entitlement to a benefit under the Health Services Insurance Act.
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
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.
5.3 Payments to Hospitals
6.0Recognition Given to
Federal Transfers
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.
No legislative amendments to the Act or the regulations in
2013-2014 had an effect on payments to hospitals.
Manitoba routinely 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.
In addition, Manitoba Health, Healthy Living and Seniors cites
the federal contribution from the First Ministers Ten Year Plan
to Strengthen Health Care (the 2004 Health Accord—Wait
Time Reduction Fund) in funding letters to the regional health
authorities and other organizations which are implementing
programs using this funding.
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
canada health act – annual report 2013-2014
79
CHAPTER 3: manitoba
Registered Persons
1. Number as of March 31st (#).1
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
1,228,246
1,230,270
1,265,059
1,271,388
1,289,268
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
96
96
96
96
96
not available
not available
not available
not available
not available
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
4. Number of private for-profit facilities
providing insured health services (#).
1
1
1
1
1
5. Payments to private for-profit facilities
for insured health services ($).
1,570,832
1,541,540
2,005,150
1,928,985
2,040,914
Public Facilities
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 ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
2,626
2,844
2,899
2,690
2,978
21,612,535
27,092,558
26,478,561
25,548,935
29,138,109
28,729
30,983
29,070
31,270
33,999
8,655,118
10,454,203
10,706,338
10,073,238
11,830,872
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12. Total number of claims, out-patient (#).
13. Total payments, out-patient ($).
552
634
646
628
722
1,924,044
2,454,364
1,913,457
4,317,523
1,826,483
10,097
10,706
11,311
11,408
12,145
2,954,321
3,022,630
3,226,581
3,193,548
3,080,536
1. Population as of March 31, 2014
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canada health act – annual report 2013-2014
CHAPTER 3: manitoba
Insured Physician Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
2,121
2,276
2,322
2,354
2,354
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
17. Total payments for services provided
by physicians paid through all payment
methods ($).
843,087,000
920,890,000
927,916,000 988,164,000
1,082,193,000
18. Total payments for services provided by
physicians paid through fee-for-service ($).
552,890,200
553,924,806
595,083,828
593,129,217
659,208,383
14. Number of participating physicians (#).
15. Number of opted-out physicians (#).
16. Number of non-participating physicians (#).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
237,192
267,122
231,683
238,400
226,473
10,287,990
9,909,927
10,989,977
11,127,080
11,137,758
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
6,768
7,226
8,285
7,984
8,216
627,563
953,272
703,353
1,148,432
888,084
Insured Surgical-Dental Services Within Own Province or Territory
23. Number of participating dentists (#).
24. Number of services provided (#).
25. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
135
133
131
160
166
5,950
5,475
5,290
5,236
5,656
1,701,655
1,522,545
1,468,524
1,231,972
1,493,071
canada health act – annual report 2013-2014
81
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canada health act – annual report 2013-2014
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Saskatchewan
Introduction
The Saskatchewan Ministry of Health supports a health care
system that puts patients first and encourages leadership from
boards, management, and health professionals at all levels.
The Ministry is dedicated to achieving a responsive, integrated,
and efficient health system that enables people to achieve their
best possible health. The Ministry strives to explore innovative
approaches and set bold targets for the health system in four
areas: better health, better care, better value, and better teams.
The system-wide focus on Lean management processes puts
the needs and values of patients and families at the forefront of
both planning and the delivery of care.
The health care system in Saskatchewan is complex. It includes
12 regional health authorities (health regions), the Saskatchewan
Cancer Agency, 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.
1.0 Public Administration
1.1Health Care Insurance Plan and Public Authority
The provincial government is responsible for funding and
ensuring the provision of insured hospital, physician and surgicaldental services in Saskatchewan. Section 6.1 of the Department
of Health 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
The Ministry provides governance training, including effective
strategic oversight to support the Boards of Directors of health
regions and the Saskatchewan Cancer Agency.
• make grants or provide subsidies to stimulate and develop
public health research, and to conduct surveys and studies in
the area of public health.
The Ministry assists health regions, the Saskatchewan
Cancer Agency, and other stakeholders to recruit and retain
health care providers, including nurses and physicians. The
Ministry also works in partnership with organizations at local,
regional, provincial, national, and international levels to provide
Saskatchewan residents with access to quality health care.
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.
For more information about the Ministry’s programs and services,
please visit www.saskatchewan.ca.
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 Department of Health 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
prescribes that the Minister of Health submit an annual report
concerning the medical care insurance plan to the Legislative
Assembly.
The Regional Health Services Act prescribes 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.
Section 54 of the Regional Health Services Act requires that
regional health authorities and the Cancer Agency shall 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 a financial and 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 to regional health
authorities, to the Saskatchewan Cancer Agency, and to
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, shall 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, 2014.
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 or are available on their
websites.
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
84
canada health act – annual report 2013-2014
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 (the Act) gives
the Minister the authority to provide funding to a regional health
authority (health region) 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 operational, financial
and health service plans for ministerial approval (sections 50-51);
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 24 hours a day, 365 days a year 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
comprehensive 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 health regions, 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: www.health.gov.sk.ca/physician-information.
As of March 31, 2014, there were 2,165 physicians licensed to
practice in the province and eligible to participate in the medical
care insurance plan.
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, 2014, there were no opted-out physicians in
Saskatchewan.
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, 2014.
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.
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.
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85
CHAPTER 3: SASKATCHEWAN
2.4Uninsured Hospital, Physician and
Surgical-Dental Services
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 health
region 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; surgicaldental 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.
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 medically necessary 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 2013-2014.
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canada health act – annual report 2013-2014
3.0Universality
3.1Eligibility
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, 2013, was 1,121,755.
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.
On June 30, 2013 there were 17,318 such temporary residents
registered with the Saskatchewan Ministry of Health.
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.
4.2Coverage During Temporary Absences
in Canada
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.
4.3Coverage 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, and
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 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 2013-2014.
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 Department of Health 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.
Section 6.6 of the Department of Health 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.
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-
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
canada health act – annual report 2013-2014
87
CHAPTER 3: SASKATCHEWAN
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 outof-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.
Out-of-Country
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.
The Saskatchewan Human Rights Code prohibits discrimination
in providing public services, which include insured health
services, on the basis of race, creed, religion, colour, sex,
sexual orientation, family status, marital status, disability, age,
nationality, ancestry or place of origin.
The Saskatchewan Ministry of Health continues to place priority
on promoting surgical access and improving the province’s
surgical system.
Sooner, Safer, Smarter: A Plan to Transform the Surgical
Patient Experience was released on March 29, 2010. The plan
guided efforts to improve the surgical experience and reduce
surgical wait times to a maximum of three months by March 31,
2014, while ensuring shorter wait times can be sustained into
the future. Eight out of 10 regional health authorities (health
regions) were near or achieved the target. The two remaining
health regions are expected to achieve the target in 2014-2015.
The four-year plan was in response to recommendations in the
Patient First Review, and was developed with assistance from
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canada health act – annual report 2013-2014
stakeholder advisory groups. It was designed to improve the
patient’s experience across the entire continuum of care — from
initial contact with a health provider, to surgery, to recuperation in
the community.
To achieve the access targets, regional health authorities
contracted with third party providers to deliver medically
necessary surgical and diagnostic imaging. Saskatchewan
remains committed to the principles of publicly funded, publicly
administered health care. Partnerships between health regions
and third-party providers are based on the understanding that
patients will not have to pay additional fees for services in a
private facility, or be able to ‘jump the queue’. Patients are
scheduled through health region booking systems to ensure
all patients are on a single list. Third-party facilities and staff
must meet safety, quality and privacy requirements, and be fully
licensed and accredited.
As of March 31, 2014, there were 2,165 physicians licensed to
practice in the province and eligible to participate in the Medical
Care Insurance Plan. Of these, 1,160 (53.6 percent) were family
practitioners and 1,005 (46.4 percent) were specialists.
As of March 31, 2014, there were approximately 441 practicing
dentists and dental surgeons located in all major centres in
Saskatchewan. Eighty-two provided services insured under the
Medical Services Plan.
In May 2009, the Government of Saskatchewan released the
Physician Recruitment Strategy in an effort to address provincewide physician shortages. In 2013-2014 funding supported
several recruitment initiatives:
• 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. Postgraduate seats were offered in Regina, Prince Albert, Swift
Current, North Battleford and La Ronge.
• 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.
In addition to the initiatives noted above, the Ministry provides
various practicing establishment grants, training grants,
and residency positions in exchange for return-of-service
commitments. The Ministry funds compensation mechanisms for
emergency room coverage to ensure patients have access to
emergency medical services.
CHAPTER 3: SASKATCHEWAN
There are also a number of programs to stabilize and support
medical services in rural areas, such as the following:
• The Saskatchewan Medical Association is funded to provide
locum relief to rural physicians through the Locum Service
Program while they take vacation, education or other leave.
• The Northern Medical Services Program is a tripartite
endeavour of the Ministry of Health, Health Canada and the
University of Saskatchewan to help stabilize the supply of
physicians in northern Saskatchewan.
• The Northern Telehealth Network provides physicians in
remote or isolated areas with access to colleagues, specialty
expertise and continuing education.
Other Programs
• 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.
• Support is provided to initiatives for physicians to use allied
health professionals and enhance the integration of medical
services with other community-based services through the
Primary Health Services Program.
• A Long Service Retention Program rewards physicians who
work in the province for 10 or more years.
• The Parental Leave Program was developed in 2004 to
provide benefits for self-employed physicians who take a
maternity, paternity or adoption child care leave from clinical
practice.
5.2 Physician Compensation
In February 2011, the Government of Saskatchewan signed
a four year agreement with the Saskatchewan Medical
Association covering the term of April 1, 2009 to March 31, 2013.
Negotiations are currently underway on a new agreement.
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.
Coverage Programs; and $354.1 million in non-fee-for-service
expenditures. There was also an additional $53.3 million for
other Saskatchewan Medical Association and bursary programs.
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.
Regional health authorities provide an annual report on the
aggregate financial results of their operations.
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 2013-2014 Annual Report, the
Government of Saskatchewan 2013-2014 Budget and related
documents, its 2013-2014 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.
Fee-for-service is the most widely used method of compensating
physicians for insured health services in Saskatchewan,
although sessional payments and 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 2013-2014 amounted to $873.5 million: $488.6 million for
fee-for-service billings; $30.7 million for Specialist Emergency
canada health act – annual report 2013-2014
89
CHAPTER 3: SASKATCHEWAN
Registered Persons
1. Number as of March 31st (#).
2009–20010
2010–2011
2011–2012
1,036,284
1,070,477
1,084,127
2012–2013
1
1,090,953
2013–2014
1
1,121,755
Insured Hospital Services Within Own Province or Territory
Public Facilities1
2. Number (#).
3. Payments for insured health services ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
67
66
66
66
66
1,556,078,000
2
1,636,013,000
2
1,694,858,000
2
1,777,208,000
2
1,846,795,000
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
4. Number of private for-profit facilities
providing insured health services (#).
0
3
5
4
4
5. Payments to private for-profit facilities
for insured health services ($).
0
Not Available
Private For-Profit Facilities
3
Not Available
3
Not Available
3
Not Available
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
5,722
4,304
5,258
5,433
4,845
53,119,000
48,700,300
51,418,800
54,483,700
53,004,700
71,123
67,689
65,916
74,201
67,387
21,497,100
21,282,400
22,268,800
26,716,300
24,736,300
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12. Total number of claims, out-patient (#).
13. Total payments, out-patient ($).
398
295
400
388
374
2,755,200
3,401,000
8,186,600
2,007,000
2,271,900
2,189
1,992
2,646
1,938
1,730
1,810,000
1,796,700
3,203,800
1,511,300
1,606,100
4
1. Saskatchewan’s numbers as of June 30, 2013.
2. This number includes estimated government funding to regional health authorities in their annual audited financial statements.
— Includes acute care services, specialized hospital services, and in-hospital specialist services.
— Does not include inpatient mental health, or addiction treatment services.
— Does not include payments to Saskatchewan Cancer Agency for out-patient chemotherapy and radiation.
3. Private facilities providing surgical services and computed tomography scans receive payments for these services under contract with regional health authorities. The Ministry of
Health does not provide payments to these facilities.
4. Increase in 2011-12 was due to a cluster of high cost procedures Saskatchewan residents received in the United States.
90
canada health act – annual report 2013-2014
2
3
CHAPTER 3: SASKATCHEWAN
Insured Physician Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
1,882
1,946
1,985
2,044
2,165
15. Number of opted-out physicians (#).
0
0
0
0
0
16. Number of non-participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment methods ($).
651,437,652
714,441,498
794,901,943
823,656,225
873,484,838
18. Total payments for services provided by
physicians paid through fee-for-service ($).
410,875,422
14. Number of participating physicians (#).
5,6
457,194,531
5,6
457,307,474
5
480,173,762
5
488,651,587
5
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
586,621
610,328
623,778
659,994
697,161
29,037,662
31,505,813
32,103,002
33,658,928
35,703,160
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
not available
not available
not available
not available
not available
1,299,600
1,324,100
2,279,100
1,199,100
1,484,200
Insured Surgical-Dental Services Within Own Province or Territory
23. Number of participating dentists (#).
24. Number of services provided (#).
25. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
70
85
93
88
82
22,349
17,800
17,420
18,123
16,014
2,013,007
1,827,088
1,719,770
1,710,397
1,669,803
5. 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.
6. Figures have been revised to be consistent with the Annual Statistical Report (2009-10 to 2010-11).
canada health act – annual report 2013-2014
91
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canada health act – annual report 2013-2014
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
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 past fiscal year featured many accomplishments including
ensuring Albertans have access to innovative, high quality
primary and community-based health care and support services,
improving Albertans’ wellness by protecting and promoting
health, and enhancing health system accountability and
performance.
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 achieve a sustainable and accountable
health system; promote and protect the health of Albertans; and
support the well-being and independence of seniors. Alberta
Health’s core business is improving Albertans’ health status over
time.
Over the past year, working with Alberta Health Services, Alberta
Health has made significant progress towards achieving three
key goals:
Goal 1: Enhanced health system accountability
and performance
• The Alberta Health Act came into force on January 1, 2014.
In conjunction with the Act, the government established a
Health Charter and began establishing the Office of the
Alberta Health Advocates to assist Albertans in navigating
the health system. The Health Advocate, the current Mental
Health Patient Advocate and a new Seniors’ Advocate will
be located in the office.
• In 2013-2014, capital funding was provided for province-wide
heliport upgrades, Edmonton’s Stollery Children’s Hospital
Critical Care Program, vascular surgery and women’s health
projects at the Peter Lougheed Hospital in Calgary, the
exterior maintenance of Northern Lights Regional Health
Centre in Fort McMurray, planning the Whitecourt Hospital,
and Continued Support for the Alberta Supportive Living
initiative to build more supportive living spaces across the
province.
• T
he new Central Alberta Cancer Centre officially opened in
Red Deer. The new facility ensures fewer people will need to
travel to Edmonton or Calgary to access cancer services and
treatment.
Goal 2: Improving wellness of Albertans by
protecting and promoting health
• The Human Tissue and Organ Donation Amendment Act was
proclaimed on November 7, 2013 to improve Alberta’s organ
and tissue donation rates and lower transplant wait times
across the country. The legislation establishes an agency to
co-ordinate organ and tissue donation activities in Alberta,
and creates an organ and tissue consent-to-donate registry.
• In June 2013, the Insulin Pump Therapy program was
launched to provide funding for the cost of insulin pumps
and basic diabetic supplies for Alberta residents with Type 1
Diabetes Mellitus who meet eligibility criteria. The program
enables patient education and training supports for the safe
and appropriate use of insulin pumps, and helps diabetics
manage their condition and improve their quality of life. Over
1,000 Albertans have benefited from the program since the
program was launched.
• Alberta
announced steps to protect all young Albertans from
a cancer causing virus by offering the human papillomavirus
(HPV) vaccine to Grade 5 male students in fall 2014. A fouryear catch-up program will also be available for Grade 9 boys.
Goal 3: Albertans have access to innovative, high
quality primary and community based health care
and support services
• Primary
health care was further strengthened through a
compensation agreement with Alberta’s physicians. The
seven-year agreement covers 2011-2018, and marks the
start of a new long-term relationship with the Alberta Medical
Association that will ensure patient-centered care and a
strong health system for years to come.
canada health act – annual report 2013-2014
93
CHAPTER 3: alberta
• S
tarting April 1, 2014, pharmacies are further supported to
bring community-based health care closer to home. These
primary health care services include customized medication
assessments, tobacco cessation counselling and new
medication management tools for diabetics.
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.
1.0 Public Administration
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.
1.1Health Care Insurance Plan and Public Authority
Alberta Health administers and operates the Alberta Health Care
Insurance Plan on a non-profit basis and 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 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 Government Accountability Act establishes
the planning, reporting, and accountability structures that
government and accountable organizations must adhere to.
1.3 Audit of Accounts
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 its audit of Alberta Health on May 31, 2014 and
indicated that the statements fairly represent, in all material
respects, the financial position and results of operations for the
year ended March 31, 2014.
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 nonhospital surgical facilities. A directory of approved hospitals in
Alberta can be found at: www.health.alberta.ca/services/healthbenefits-services.html.
During 2013–2014, no amendments were made to the legislation
regarding insured hospital services.
The publicly funded services provided by approved hospitals in
Alberta range from the most advanced levels of diagnostic and
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canada health act – annual report 2013-2014
2.2 Insured Physician Services
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.
Alberta had 8,466 physicians participating under the Alberta
Health Care Insurance Plan as of March 31, 2014. Within this,
6,964 physicians were paid exclusively under fee-for-service
(FFS), 723 were compensated solely under an Alternative
Relationship Plan (ARP) and the remaining 779 physicians
received compensation from both FFS and ARP. Out of the 8,446
physicians, 3,289 were registered providers in Primary Care
Networks as of March 31, 2014.
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. 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
CHAPTER 3: alberta
reimbursement for any amounts paid by the patient for receiving
health services from the opted-out physician. As of March 31,
2014, there were no opted-out physicians 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: http://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, 2014, no dentists were opted-out of the
Alberta Health Care Insurance Plan.
2.4Uninsured 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 non-standard
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 NonStandard Goods or Services is available at: www.health.alberta.
ca/newsroom/pub-health-authorities.html.
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 or are returning landed immigrants, or 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-bycase basis.
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:
canada health act – annual report 2013-2014
95
CHAPTER 3: alberta
• 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 came into force April 1, 2013, which
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 with the Alberta Health
Care Insurance Plan. 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, 2014, there were 4,228,125 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, 2014, there were
298 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 110,493
people covered under these conditions as of March 31, 2014.
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canada health act – annual report 2013-2014
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.
4.2Coverage 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 2013-2014, 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
2013-2014.
CHAPTER 3: alberta
4.3Coverage 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.
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, 2014, was paid at a maximum of $473 per visit, with a limit
of one visit per day. Effective April 1, 2014, the rate decreased
from $473 to $423 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 that were not available in Canada. More
information on coverage during temporary absences outside
Canada is accessible at: www.health.alberta.ca/AHCIP/outsidecoverage.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 2013-2014.
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 outof-country and approval may only be given through the Out-ofCountry 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
All Alberta residents have access to insured health services
regardless of where they live in the province. Within Alberta,
Alberta Health Services provides health services across
geographic zones so that communities are more directly
connected to their local health systems and decisions can
be made closer to where care is provided. There are two
major metropolitan zones, the Calgary zone and the Capital
(Edmonton) zone, and three rural zones: North, Central and
South. Provincially-funded tertiary and quaternary level services
are concentrated in the two metropolitan zones.
Alberta Health Services is responsible for overseeing the
planning and delivery of health supports and services to more
than four million residents living in the province of Alberta. The
board or official administrator for Alberta Health Services governs
all health services in the province, working in partnership with
Alberta Health to ensure all Albertans have equal access to
health services across the province.
Primary Care Networks (PCNs) are networks of family doctors
that work with Alberta Health Services and other health
professionals to deliver the necessary health services for that
community. Each PCN is unique, developed by local area
family physicians with the local Alberta Health Services zone
and health professionals, including nurses, pharmacists, mental
health workers, exercise specialists and dietitians. This allows
and encourages the PCN to focus on the needs of the local
patient population. As of December 31, 2013, there were 42
PCNs operating throughout Alberta with more than 1,800 family
physicians and more than 1,100 other health practitioners.
The Government 2014-2017 Health Capital Plan includes funding
for new primary care clinics and acute care projects designed
to improve Albertans’ access to insured health services. These
projects include:
• T
he redevelopment of the Medicine Hat Regional Hospital and
the Chinook Regional Hospital in Lethbridge which includes
renovations to create additional ambulatory treatment space.
• A
new health centre in Edson, which will be built on a new
site to provide health care services and programs to meet the
needs of the community, including acute care, emergency and
out-patient services.
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CHAPTER 3: alberta
• A
new health centre in High Prairie to replace the existing
complex and the J.B. Wood Nursing Home. The new High
Prairie Health Centre will be built on a new site and will
include a wide range of health services such as acute care,
continuing care and community health programs.
• A
new regional hospital in Grande Prairie, which will include a
state-of-the-art cancer centre.
• N
ew residential addictions and detoxification facilities in Fort
McMurray, Medicine Hat, Red Deer, and Edmonton.
• R
enovations to the Peter Lougheed Centre in Calgary to
accommodate an expanded vascular surgery program and
women’s health program.
• R
enovations to the Stollery Children’s Health Centre to
accommodate an expanded critical care program and surgical
program.
• R
enovations to the Red Deer Regional Hospital Centre to
accommodate and expanded obstetrical program.
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 Physician
Compensation, Schedule of Medical Benefits, and Physician
Support Programs segments of the AMAA are evergreen and
do not have a termination date. 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. The established increases apply to
compensation under the fee-for-service and ARP compensation
models, and both parties undertake an allocation process in
which increases are divided between the 31 medical sections.
The AMAA also establishes that funding for support and
assistance programs to physicians, for example, to provide
payments to physicians for on-call work, continuing medical
education and learning, rural incentives, etc.
• N
ew or upgraded heliports at 13 health centres throughout
Alberta.
The Ministry also funds Primary Care Networks (PCNs) in
which family physicians work with Alberta Health Services 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. These payments also compensate physicians
for services which are currently not remunerated through feefor-service or other funding methods. Each PCN decides how
funds will be allocated based on alignment with PCN policy and
approved business plans.
• A
new state-of-the-art cancer centre in Calgary and major
renovations to the Cross Cancer Institute in Edmonton.
5.3 Payments to Hospitals
• R
enovations to the Raymond Health Centre and the Taber
Health Centre to consolidate and expand primary care
services.
• A
new continuing care centre and a new community health
centre to accommodate the growing health needs in the Fort
McMurray.
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.
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. ARPs are
unique in that, by creating baskets of services and paying a rate
for each of these baskets, they offer an alternative funding model
to the way government has traditionally funded health care
service delivery by physicians.
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canada health act – annual report 2013-2014
The Regional Health Authorities Act governs the funding of
Alberta’s single regional health authority—Alberta Health
Services. The provision of insured health services by Alberta
Health Services 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 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.
According to the Health Care Protection Act, Ministerial approval
for a service agreement shall not be given unless:
• 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;
CHAPTER 3: alberta
• the proposed surgical services will not have an adverse
impact on the province’s publicly funded and publicly
administered health system;
6.0Recognition Given to
Federal Transfers
• there will be an expected benefit to the public;
The Government of Alberta publicly acknowledged the federal
contributions provided through the Canada Health Transfer in its
2013-2014 publications.
• A
lberta Health Services 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 Alberta
Health Services 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.
canada health act – annual report 2013-2014
99
CHAPTER 3: alberta
Registered Persons
1. Number as of March 31st (#).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
3,692,001
3,786,238
3,910,117
4,068,062
4,228,125
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
223
225
225
226
225
not available
not available
not available
not available
not available
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
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
Public Facilities
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 ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
5,411
5,689
5,707
5,657
6,221
33,077,528
37,887,391
36,659,355
37,628,241
42,196,441
105,792
110,757
109,703
112,703
119,873
26,879,756
29,382,381
29,687,993
31,763,550
35,627,482
Insured Hospital Services Provided Outside Canada1
10. Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12. Total number of claims, out-patient (#).
13. Total payments, out-patient ($).
4,506
3,075
3,613
4,921
4,209
2
425,269
294,509
339,343
472,489
393,925
2
4,544
3,425
4,414
5,461
5,128
2
306,639
267,120
467,081
440,188
487,055
2
1. These data do not include claims/payments for Alberta residents who have received health services out of country through the Out-of-Country Health Services Committee
application process.
2. Data reported for out of country hospital services are accurate as of June 30, 2014, however does not reflect claims still being processed for 2013-2014.
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Insured Physician Services Within Own Province or Territory 3
14. Number of participating physicians (#).4
15. Number of opted-out physicians (#).
16. Number of non-participating physicians (#).
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18. Total payments for services provided by
physicians paid through fee-for-service ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
6,482
6,743
7,706
8,100
8,466
5
0
6
not applicable
6
not applicable
6
0
0
6
6
0
0
0
0
1
not available
not available
not available
not available
not available
2,133,199,354
2,302,481,210
2,450,159,476
2,584,944,346
2,788,382,882
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
599,596
611,503
616,786
751,061
663,164
24,621,807
25,340,583
27,960,901
27,940,698
30,710,409
Insured Physician Services Provided Outside Canada7
21. Number of services (#).
22. Total payments ($).
22,070
15,654
42,643
8
39,317
8
not available
9
1,266,451
909,715
2,573,169
8
2,435,305
8
not available
9
Insured Surgical-Dental Services Within Own Province or Territory
23. Number of participating dentists (#).
24. Number of services provided (#).
25. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
212
207
218
224
218
18,963
21,052
20,784
23,014
24,995
4,847,467
5,747,026
6,293,750
7,077,327
7,317,869
3. Data for this table are processed 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, and receive compensation from both feefor-service and alternative relationship plan. Prior years reflected physicians that were only paid under fee-for-service.
5. 6,964 of these are paid under fee for service, 723 under an Alternative Relationship Plan and the remaining 779 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 out of country 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 2013-2014.
canada health act – annual report 2013-2014
101
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canada health act – annual report 2013-2014
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
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.
The Ministry works with health authorities, care providers,
agencies, and other groups to guide and enhance the
province’s health services, provide access to care, and ensure
British Columbians are supported in their efforts to maintain
and improve their health. The Ministry provides leadership,
direction, and support to these service delivery partners and
sets province-wide goals, standards, and expectations for health
service delivery by health authorities. The province’s six health
authorities are the organizations primarily responsible for health
service delivery.
On October 1, 2013, Health Canada’s role in health programming
and service delivery to First Nations was transferred to the
newly created First Nations Health Authority (FNHA) as part of
the British Columbia Tripartite Framework Agreement on First
Nation Health Governance. While the FNHA is an independent
body, it is building a strong relationship with the Ministry and
its six health authorities in order to improve coordination of
programming and services to First Nation residents.
The delivery of health services and the health of the population
are monitored by the Ministry on an ongoing basis. These
activities inform the Ministry’s strategic planning and policy
direction to ensure the delivery of health information and services
continue to meet the needs of British Columbians. To read more
about British Columbia’s publicly funded health system, please
refer to the BC Ministry of Health 2013-2014 Annual Service
Plan Report:
http://bcbudget.gov.bc.ca/annual_reports/2013_2014/pdf/ministry/
hlth.pdf
1.0 Public Administration
1.1Health Care Insurance Plan and Public Authority
The Ministry of Health (the Ministry) sets goals, standards, and
performance agreements for provincial health service delivery
and works with the 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.
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.
In 2013-2014, the Medical and Health Care Services Regulation
was amended to remove auditing powers from the Health Care
Practitioner’s Special Committee for Audit. This committee was
inadvertently delegated full audit powers in 2008. The purpose
of this committee has always been to hold hearings and not
to perform audits. This regulatory amendment also changed
the name of the committee to reflect its purpose and it is now
called the Health Care Practitioners Special Committee for
canada health act – annual report 2013-2014
103
CHAPTER 3: british columbia
Audit Hearings. This regulation was also amended to make a
scheduled MSP premium rates increase.
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 extensive 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 Ministry reports through additional publications, including:
• the Vital Statistics Annual Report, available at:
www.vs.gov.bc.ca/stats/annual/
• the Provincial Health Officer’s Reports (on the health of the
population), available at: www.health.gov.bc.ca/pho/reports/
annual.html
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: www.health.
gov.bc.ca/msp/legislation/msc.html
In addition, the MSC Financial Statement is published annually;
it contains an alphabetical listing of payments made by the MSC
to practitioners, groups, clinics, hospitals, and diagnostic facilities
for each fiscal year. The MSC Financial Statement for the 20132014 fiscal year is available at: http://www.health.gov.bc.ca/msp/
legislation/pdf/bluebook2014.pdf
1.3 Audit of Accounts
The Ministry is subject to audit of accounts and financial
transactions through:
• T
he Office of the Comptroller General (OCG) Internal Audit
and Advisory Services; the government’s internal auditor. The
OCG determines the scope of the internal audits and timing of
the audits. The OCG reports can be located on the following
website link: www.fin.gov.bc.ca/ocg/ias/Audit_Reports.htm
• T
he 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
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canada health act – annual report 2013-2014
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: http://www.fin.gov.bc.ca/ocg/pa/13_14/
Public%20Accounts%2013-14.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.
• H
IBC 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: http://www.health.gov.bc.ca/insurance/status_reports.html
• H
IBC applies 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.
RSBC is required to comply with all applicable laws, including
the:
• Ombudsman Act;
• Business Practices and Consumer Protection Act; and
• Financial Administration Act.
• F
reedom 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).
CHAPTER 3: british colombia
2.0Comprehensiveness
2.1 Insured Hospital Services
The Hospital Act and Hospital Act Regulation provide authority
for the Minister of Health (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.
• o ther 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;
• d iagnostic services (e.g., laboratory or radiological
procedures);
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.
• use of operating room facilities;
In 2013-2014, the Hospital Act Regulation was amended to
require Hospital Act facilities to report to the Minister when
certain serious adverse events occur.
• d rugs and medications administered in a medically necessary
service provided to the beneficiary; and
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;
• d rugs, biologicals, and related preparations which are
required by the patient and administered in hospital;
• laboratory and radiological procedures and related
interpretations;
• d iagnostic procedures and the necessary interpretations, as
approved by the Minister;
• u se 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;
• o ther rehabilitation services, including occupational and
speech therapy; and
• e quipment 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;
• a ny 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:
• m
edically required services provided to beneficiaries
(residents of British Columbia who are enrolled in MSP in
canada health act – annual report 2013-2014
105
CHAPTER 3: british columbia
accordance with section 7 of the MPA) by a physician enrolled
with MSP; and
• m
edically 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
2013-2014, 10,119 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 optedout. 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 2013-2014,
MSP had five 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. Physicians who
wish to modify the payment schedule must 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.
106
canada health act – annual report 2013-2014
During fiscal year 2013-2014, 108 physician services were
added as MSP insured benefits to reflect current practice
standards including, for example, the introduction of the fecal
immunochemical test as part of the provincial colorectal cancer
screening program, and a revision to the payment schedule for
the Section of Plastic Surgery.
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 212 dentists enrolled with MSP in 20132014 (includes only paediatric dentists, oral surgeons, dental
surgeons, pediatric dentists, oral medicine, and orthodontist
billing through FFS).
2.4Uninsured 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.
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
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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. Insured
hospital services do not include transportation between place of
residence and hospital; however, health authorities are required
to fund some of these services by Ministry policy, with a small
user charge.
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 of Health (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-list 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.
3.0Universality
• makes his or her home in British Columbia,
• 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.
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 in
which residence is established plus two 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.
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.
The number of residents registered with MSP as of March 31,
2014, was 4,625,653.
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 are
eligible for benefits when deemed to be residents under the MPA
and section 2 of the Medical and Health Care Services Regulation.
3.1Eligibility
3.3Premiums
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.
The enabling legislation is:
Section 1 of the MPA, defines a resident as a person who:
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
• is a citizen of Canada or is lawfully admitted to Canada for
permanent residence;
• M
edicare Protection Act, Part 2 — Beneficiaries section 8;
and
• M
edical and Health Care Services Regulation, Part 3 —
Premiums.
canada health act – annual report 2013-2014
107
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since January 1, 2014, are $69.25 for one person, $125.50 for a
family of two, and $138.50 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. 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.
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.
4.2Coverage During Temporary Absences
in Canada
Sections 3, 4 and 5 of the Medical and Health Care Services
Regulation of the Medicare Protection Act (MPA) 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.
Individuals leaving the province temporarily on extended
vacations, or for temporary employment, may be eligible for
coverage for up to 24 consecutive months. 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
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canada health act – annual report 2013-2014
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.
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 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 outpatient 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.
4.3Coverage During Temporary Absences
Outside Canada
The enabling legislation that defines portability of health
insurance during temporary absences outside Canada is the
Hospital Insurance Act, section 24; the Hospital Insurance Act
Regulations, Division 6; the MPA, 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 full-time 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,
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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, they 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
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; therapeutic abortions; 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 Forces, Workers’ Compensation
Board, Department of Veterans Affairs, Correctional Services
of Canada); services requested by a “third party”; team
conference(s); genetic screening and other genetic investigation,
including DNA probes; procedures still in the experimental or
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-forprofit 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
Access to insured services continues to be enhanced:
• T
he 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.
• T
he 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.
• T
he 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.
• T
he 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.
These programs include:
canada health act – annual report 2013-2014
109
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• R
ural Retention Program — provides eligible physicians
(estimated at 2,400) with fee premiums. The program is
available to resident and visiting physicians and locums,
and also provides a flat fee sum for eligible physicians who
reside and practice in a rural community.
• Isolation Allowance Fund — provides funding to
communities with fewer than four physicians and no
hospital, and where the Medical On-Call Availability
Program, Call-Back, or Doctor of the Day payments are
not available.
• N
orthern and Isolation Travel Assistance Outreach
Program — provides funding support for approved
physicians who visit rural and isolated communities to
provide medical services.
• R
ural General Practitioner Locum Program — assists
rural GPs in taking reasonable periods of leave from
their practices by providing up to 43 days of paid locum
coverage per year. This program assisted physicians in
approximately 63 small communities to attend continuing
medical education and/or take vacation relief.
• R
ural Specialist Locum Program — assists rural specialists
in taking vacations and continuing medical education by
providing paid locum support. The program provided locum
support for core specialists in 18 rural communities for
vacation relief or assistance while physician recruitment
efforts were underway.
• R
ural Emergency Enhancement Fund — provides funding
to physician groups in eligible rural communities that
commit to work as a team to maintain public access to
emergency department services in rural hospitals.
• R
ural Education Action Plan — supports the training needs
of physicians in rural practice through several components,
including rural practice experience for medical students
and enhanced skills for practicing physicians.
• R
ural Continuing Medical Education — offers eligible
rural physicians funding support to acquire and maintain
medical skills and expertise for rural practice. The amount
is dependent upon the designation of the community
and the length of time the physician has practiced in the
community.
• R
ecruitment Incentive Fund — provides an incentive to
physicians to fill vacancies that are part of the Physician
Supply Plan in eligible rural communities.
• R
ural Loan Forgiveness Program — decreases British
Columbia student loans by 20 percent for each year of
rural practice for physicians, nurse practitioners, nurses,
midwives, and pharmacists.
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canada health act – annual report 2013-2014
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.
The Ministry has committed to a significant number of major
capital projects for new or existing hospitals in locations including
Surrey, Vancouver, Vernon, Kelowna, Courtenay/Comox and
Campbell River, that are being developed as public-private
partnerships. Major capital projects are overseen by Project
Boards comprised of senior executives from health authorities
and government to ensure projects are appropriately defined and
stay within their approved scope, cost and completion schedules.
5.2 Physician Compensation
The PMA is a formal agreement signed by the Government
of British Columbia, Doctors of BC, and the Medical Services
Commission (MSC). In July 2012, doctors in BC ratified a new
four-year agreement that supports ongoing efforts to recruit and
retain physicians while also improving access to specialists and
care in rural and remote communities.
In general terms, the PMA provides the framework for managing
the ongoing relationship between the government, health
authorities, physicians, and Doctors of BC. Its Subsidiary
Agreements and Appendices provide additional detail related to:
• P
hysician benefits (the Benefits Subsidiary Agreement)
— outlines programs that provide contractually negotiated
benefits.
• R
ural programs (the Rural Practice Subsidiary Agreement)
— provides financial incentives for physicians to locate and
establish their practice in rural and remote communities.
• A
lternative Payment Programs (The Alternative Payments
Subsidiary Agreement) — outlines the specific terms and
conditions applicable to contract, salaried and sessional
payment agreements for physician services.
• P
rograms specific to GPs (General Practitioner Subsidiary
Agreement) and Specialists (Specialist Subsidiary Agreement)
— establishes the General Practitioners Services Committee
(GPSC), the Specialist Services Committee, and the Shared
Care Committee.
• A
ppendix G — Medical On-Call/Availability Program (MOCAP)
provides payments to physicians and physician groups who
provide coverage for patients other than their own or those of
their call groups, which includes funding for Doctor of the Day
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payments that are not covered by GPSC incentive payments.
This provides greater flexibility for health authorities in
maintaining physician “on call” coverage and hospital patient
intake services.
• A
ppendix J — Laboratory Medicine Fee Agreement
establishes targets for total annual out-patient laboratory
expenditures and the formation of the Laboratory Reform
Committee.
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 pays for medically
required dental services and medically required dental surgical
services performed in a hospital; the rest is self-pay.
5.3 Payments to Hospitals
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 the Medical
Services Plan (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.
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 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.
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 hospitals, 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.
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)
negotiated a Memorandum of Understanding that covers the
following services: dental surgery; oral surgery; orthodontic
services; oral medicine; and dental technical procedures. Both
the province and the BCDA meet through a Joint Dental Surgery
Policy Committee for the duration of the agreement.
Compensation Methods for Physicians
and Dentists
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
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 hips
and knees, and patient-focused funding). Since it is specifically
earmarked, it must be reported on separately.
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 and payments for prescription drugs covered under
PharmaCare.
The Ministry introduced patient-focused funding (PFF) in
2010-2011 under which a portion of eligible acute care funding
was based on actual workload performed. The Ministry continued
the PFF initiative in 2011-2012, 2012-2013 and 2013-14,
and health authorities participated in PFF initiatives such as
Emergency Department Pay-for-Performance, Procedural Care
canada health act – annual report 2013-2014
111
CHAPTER 3: british columbia
Programs (e.g., Magnetic Resonance Imaging), Community
Programs, Activity Based Funding, and National Surgical Quality
Improvement). In 2013-2014, the Ministry continued to examine
alternative funding methodologies including the use of pay-forperformance and activity-based funding.
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. In 2013-2014, a full continuum of
care (acute, residential, community care, public and preventive
health, adult mental health, addictions programs, etc.) was
provided through five regional health authorities and the
Provincial Health Services Authority (responsible for provincewide programs).
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canada health act – annual report 2013-2014
6.0Recognition Given to
Federal Transfers
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 2013-2014, these
documents included:
• E
stimates, Fiscal Year Ending March 31, 2014, available
at: http://www.bcbudget.gov.bc.ca/2013/estimates/2013_
Estimates.pdf
• B
udget and Fiscal Plan 2013-2014 and 2015-2016, available
at: http://www.bcbudget.gov.bc.ca/2013_june_update/
bfp/2013_June_Budget_Fiscal_Plan.pdf
• P
ublic Accounts 2013-2014, available at: http://www.fin.gov.
bc.ca/ocg/pa/13_14/Public%20Accounts%2013-14.pdf
CHAPTER 3: british colombia
Registered Persons
1. Number as of March 31st (#).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
4,469,177
4,521,503
4,565,864
4,594,940
4,625,653
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
119
119
120
120
120
not available
not available
not available
not available
not available
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
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
Public Facilities
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 ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
6,846
5,909
6,551
6,886
7,038
64,655,739
67,078,612
69,785,313
68,904,638
73,641,805
87,948
78,075
86,544
97,088
93,382
24,188,890
21,830,298
25,327,347
28,643,797
29,362,893
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12. Total number of claims, out-patient (#).
13. Total payments, out-patient ($).
3,056
2,469
2,961
4,091
2,689
6,058,867
4,452,628
4,152,060
4,520,778
4,747,415
1,920
1,940
2,468
2,915
2,709
1,174,112
999,733
1,301,179
1,646,810
2,098,735
General information for statistical indicators 1-2: Historical and current data may differ from report to report because of changes in data sources, definitions and methodology from year
to year. The count of facilities in this table may not match counts produced from the Discharge Abstract Database, the MIS reporting system, or the Societies Act because each reporting
system has different approaches to counting multiple site facilities and categorizing them by function.
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: $8.6 billion in 2009-2010, $9.2 billion in
2010-2011, $9.7 billion in 2011-2012, $10.1 billion in 2012-2013, and $10.5 billion in 2013/14.
canada health act – annual report 2013-2014
113
CHAPTER 3: british columbia
Insured Physician Services Within Own Province or Territory
2009–2010
14. Number of participating physicians (#).
9,201
2010–2011
3
9,417
2011–2012
9,628
3
2012–2013
9,947
3
2013–2014
3
10,119
15. Number of opted-out physicians (#).
5
5
5
4
5
16. Number of non-participating physicians (#).
2
not available
not available
not available
not available
not available
not available
not available
not available
not available
2,460,943,779
2,541,874,909
2,619,943,719
2,656,938,267
2,758,295,568
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18. Total payments for services provided by
physicians paid through fee-for-service ($).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
622,277
625,981
653,387
628,705
681,401
29,560,007
30,698,752
32,453,109
32,502,933
33,860,748
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
75,910
82,247
91,026
83,050
76,084
4,013,791
4,240,090
4,869,497
4,340,034
4,148,174
Insured Surgical-Dental Services Within Own Province or Territory
23. Number of participating dentists (#).
24. Number of services provided (#).
25. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
243
236
218
217
212
50,341
51,036
52,047
50,813
54,120
8,093,266
7,991,262
8,130,009
7,903,742
8,456,773
3. The number of participating physicians in item 14 is for physicians who received payments through Fee-For-Service.
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3
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
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. Non-insured health service programs 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 - the Whitehorse General Hospital, as well as two
newly constructed medical facilities in Watson Lake (September
2013) and Dawson City (December 2013). These facilities
include a range of health-related programs including acute care
services, home care and public health units, visiting mental
health services, as well as the Community Health Centres. The
shared sites encourage increased collaboration between the
services. Additional construction has also begun on a new facility
at the Whitehorse General Hospital to house Canada’s first
magnetic resonance imaging (MRI) program north of 60.
The Yukon Government continues to utilize tele-radiology and
tele-health 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 is one NP delivering services, with a second starting in the
fall of 2014.
1.0 Public Administration
1.1Health 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
2013-2014.
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
2013-2014.
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;
• conduct surveys and research programs, and obtain statistics
for such purposes; and
• appoint inspectors and auditors to examine and obtain
information from medical records, reports, and accounts.
Specific to the Hospital Insurance Services Act, the Director,
Insured Health and Hearing Services is also responsible 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
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• p erform any other functions and discharge any other duties
assigned to the administrator by the Regulations.
Amendments to section 1, 2, 5 and 8 of the Health Care
Insurance Plan Act, and section 1, 2, 6, 9, 11 and 14 of the
Hospital Insurance Services Act were made in 2013-2014 to
clarify the rules respecting entitlement to insured health services.
This included providing the regulatory authority required to
explain the definition of, and relationship between, residency
and eligibility for the purposes of entitlement to insured health
services within regulation. Amendments were passed by the
Yukon Legislative Assembly in December of 2013, allowing for
the regulatory work that is currently underway. Proclamation of
the Act is expected in 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.
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.
An Auditor General of Canada report, Yukon Health Services and
Programs — 2011, Department of Health and Social Services
was released in 2011. 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.
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 financial year. The report is to include the financial
statements of the Corporation and the auditor’s report.
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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.
Amendments were made in 2013-2014 to section 6 and 9 to
clarify the rules respecting entitlement to insured health services.
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 2013-2014, insured in-patient and out-patient hospital services
were delivered in 15 facilities throughout the territory. These
facilities include one general hospital, two community hospitals
and 12 health 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 will take part in this process, while
Dawson City Community Hospital will take part in the next
process in 2018.
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
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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, which period may be extended by the Administrator,
provided the service could not be obtained within 24 hours of
the accident, namely: 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 has also begun construction, as part of an
expansion, to make room for a new MRI which is expected to
be operational in early 2015. This will be northern Canada’s first
MRI.
provide for insured physician services. Amendments were
made in 2013-2014 to sections 1, 2, 5 and 8 to clarify the rules
respecting entitlement to insured health services. This included
providing the regulatory authority required to explain the
definition of, and relationship between, residency and eligibility
for the purposes of entitlement to insured health services within
regulation.
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 2013-2014 was 71, along with 21
locums and 38 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 2013-2014, 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.
These measures help reduce Yukon’s reliance on out-of-territory
services.
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.
2.2 Insured Physician Services
2.3 Insured Surgical-Dental 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
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
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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.
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.
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.
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
2013-2014.
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.
2.4Uninsured Hospital, Physician and
Surgical-Dental Services
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
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.
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The process used to de-insure services covered by the Yukon
Health Insurance Plan is as follows:
Physician services — the Yukon Health Care Insurance Plan/
Yukon Medical Association 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 2013-2014.
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, 2014, 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-In-Council
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 surgicaldental services were de-insured in 2013-2014.
CHAPTER 3: yukon
3.0Universality
3.1Eligibility
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. Amendments were made in
2013-2014 to section 2 of both acts to clarify the rules respecting
entitlement to insured health services. This included providing
the regulatory authority required to explain the definition of, and
relationship between, residency and eligibility for the purposes of
entitlement to insured health services within regulation.
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 resident in
Yukon.
The number of registrants on the Yukon Health Care Insurance
Plan as of March 31, 2014 was 38,054.
3.2 Other Categories of Individuals
The Yukon Health Care Insurance Plan provides health care
coverage for other categories of individuals, as follows:
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.
4.2Coverage 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.
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Students attending educational institutions full-time outside
Yukon remain eligible for the duration of their academic studies.
The Director, Insured Health and Hearing Services may approve
other 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.
For temporary workers and missionaries, the Director, Insured
Health and Hearing Services 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. Amendments were approved in 2013 by
the Yukon Legislative Assembly with the awareness that through
regulation, Yukon intends to amend temporary absences to six
months with specified exceptions. Regulatory amendments will
receive full public consultation before taking effect.
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.
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4.3Coverage 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.
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 outof-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.
CHAPTER 3: yukon
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 extrabilling 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, Tele-health
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.
In 2013-2014, a physician Recruitment and Retention Strategy
was developed in collaboration with the Yukon Medical
Association. 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.
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 hospitals located in Whitehorse, Watson Lake, and Dawson
City are funded directly through a contribution agreement.
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 2013-2014.
6.0Recognition Given to
Federal Transfers
The Government of Yukon has acknowledged the federal
contributions provided through the Canada Health Transfer
(CHT) in its 2013-2014 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.
The Memorandum of Understanding expired on March 31, 2012.
Negotiations were ratified on October 18, 2012, for a five year
physician funding agreement.
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 2013-2014.
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
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CHAPTER 3: yukon
Registered Persons
1. Number as of March 31st (#).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
35,084
36,063
36,694
37,048
38,054
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
15
15
15
15
15
49,051,490
51,734,000
57,655,576
58,943,422
70,087,418
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
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 ($).
0
0
0
0
0
Public Facilities1
2. Number (#).
3. Payments for insured health services ($). 2
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
956
1,047
996
1,173
1,197
15,333,983
16,583,657
13,507,016
15,890,700
16,562,129
12,830
13,197
13,550
14,036
15,493
3,248,555
3,413,932
3,974,870
4,425,670
4,730,725
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).3
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
19
25
20
18
8
67,671
45,893
100,716
70,556
39,293
92
74
77
61
44
18,862
12,741
21,950
19,823
9,951
11. Total payments, in-patient ($).
12. Total number of claims, out-patient (#).
13. Total payments, out-patient ($).
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. Includes monies paid to hospitals and community nursing stations.
3. Hospitals have up to a year from date of service to bill jurisdictions. (Information is based upon date of service; therefore, 2013-14 reporting period is still open until March 31, 2015)
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Insured Physician Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
69
69
74
70
71
15. Number of opted-out physicians (#).
0
0
0
0
0
16. Number of non-participating physicians (#).
0
0
0
0
0
20,781,850
21,549,640
22,387,839
22,690,228
24,409,655
17,719,117
17,701,880
18,373,627
18,660,715
18,817,879
14. Number of participating physicians (#).
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18. Total payments for services provided by
physicians paid through fee-for-service ($).4
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
50,893
54,007
54,073
59,962
57,178
3,008,828
3,185,612
3,227,488
3,584,241
3,503,179
Insured Physician Services Provided Outside Canada
21. Number of services (#).
not available
not available
not available
not available
not available
22. Total payments ($).
not available
not available
not available
not available
not available
Insured Surgical-Dental Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
23. Number of participating dentists (#).5
4
2
3
3
2
24. Number of services provided (#).5
4
4
14
26
6
6,271
4,631
13,913
21,845
3,827
25. Total payments ($).5
4. Includes Visiting Specialists, Member Reimbursements, Locum Doctors, and Optometrist testing paid through fee-for-service. Excludes services and costs provided by alternative
payment agreements.
5. Includes direct billings for insured surgical-dental services received outside the territory.
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123
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Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Northwest Territories
Introduction
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).
During the 2013-2014 fiscal year DHSS carried out the following
legislative activities related to health care services:
• A
new Health Information Act was being drafted. The purpose
of the Health Information Act will be to set rules that health
care providers must follow for the protection and proper
sharing of clients’ personal health information. The new Act
will provide up-to-date health-specific access and protection
of privacy provisions that will apply to health care providers,
including private sector providers, such as pharmacists.
• A new Health and Social Services Professions Act was
being developed. The purpose of the proposed Act will be
to regulate several health and social services professions
under one legislative model, thereby allowing the Department
to modernize existing outdated professional legislation in a
more efficient and consistent manner. Professions currently
unlicensed in the Northwest Territories could also be regulated
under the Act in the future.
• A
mendments were made to the Medical Care Act to remove
Royal Canadian Mounted Police (RCMP) from the list of
residents not eligible for insured services. This amendment
reflects administrative practice and consistency with the
amendments to the Canada Health Act to ensure that
members of the RCMP are no longer excluded from the list of
“insured persons.”
• A
n amendment was made to the Hospital Insurance
Regulations to waive the mandatory three month waiting
period for eligibility for the NWT Health Care Plan for
the spouses and dependents of Canadian Armed Forces
members.
• W
ork on 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.
1.0 Public Administration
1.1Health Care Insurance Plan and Public Authority
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 (hereafter referred
to as 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
Reporting to the Minister, the Department and the 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] 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.
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 Health and Social Services Authority 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
canada health act – annual report 2013-2014
125
CHAPTER 3: northwest territories
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.
The Director of Medical Insurance and the Boards of
Management are responsible to the Minister, as per section 8(1)
(b) of the Canada Health Act.
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- 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);
• d rugs, biologicals and other preparations administered in the
hospital;
• surgical supplies and use of operating room;
• case room and anaesthesiology services;
• radiology and rehab therapy (physio, audio, occupational and
speech);
• p sychiatric 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);
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canada health act – annual report 2013-2014
• p hysiotherapy, speech and language pathology therapy and
occupational therapy;
• m
inor medical and surgical procedures and related supplies;
and
• p sychiatric and psychological services under an approved
hospital program.
The Minister may change, add or delete insured hospital
services, and determine whether public consultation will occur.
As outlined in the 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 in accordance with the Canada Health Act.
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). As of March 31, 2014, there were
293 physicians licensed 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
• e ye examinations, treatment and operations provided by an
ophthalmologist.
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 deleted from the tariff by:
• e stablishing a medical care plan that provides insured
services to insured persons by medical practitioners that will
CHAPTER 3: northwest territories
qualify and enable the NWT to receive transfer payments from
the Government of Canada under the Canada Health Act; and
• a pproving 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.
2.4Uninsured 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:
• in-vitro fertilization;
• third party examinations;
• dental services that are not surgical in nature;
• group immunizations;
• medical-legal services;
• advice or prescriptions done over the phone;
• services rendered to the physician’s family;
• d ressings, bandages, drugs and other consumables used at
the medical practitioner’s office;
• eye glasses and other appliances;
• plaster; and
• s ervices 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’ 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 of this report.
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.
Following the amendments to the Canada Health Act to allow
members of the Royal Canadian Mounted Police (RCMP) to
be eligible for coverage under provincial and territorial health
plans, the NWT updated the NWT Medical Care Act to ensure
that members of the RCMP were no longer excluded from
the list of NWT “insured persons.” This amendment reflected
administrative practices that were in place since April 1, 2013,
when the amendment to the Canada Health Act came into force;
and ensured that the definition of “insured person” in the Medical
Care Act is consistent with the amendment made to the Canada
Health Act.
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, 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.
As of March 31, 2014, there were 41,158 individuals registered
with the NWT Health Care Plan.
No formal provisions exist for clients to opt out of the NWT
Health Care Plan.
3.2 Other Categories of Individuals
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.
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CHAPTER 3: northwest territories
4.0Portability
4.4 Prior Approval Requirement
4.1 Minimum Waiting Period
Prior approval is required for elective services rendered in other
provinces and outside Canada. All services from private facilities
require prior approval as well.
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.
4.2Coverage During Temporary Absences
in Canada
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 adheres to
the Interprovincial Agreement on Eligibility and Portability as
described in the NWT Health Care Plan Registration Guidelines.
Once an individual has filled out the Temporary Absence form
and it is approved by the Department, 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.
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 over 19 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).
4.3Coverage 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.
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5.0Accessibility
5.1 Access to Insured Health Services
The 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.
During 2013-2014, an ongoing partnership with Dalhousie
University provides psychiatric service delivery through
telepsychiatry. Dalhousie psychiatrists are on-site in the NWT for
approximately 19 weeks per year and also provide services via
telepsychiatry for an additional 14 weeks per year. The program
provides all aspects of psychiatric care, including travel clinics,
consultations, and emergency assessments.
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
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.
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.
CHAPTER 3: northwest territories
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
press releases and other documents.
For the current reporting period these documents include:
• 2013-2014 Budget Address;
• 2013-2014 Main Estimates;
• 2013-2014 Public Accounts;
• 2 013-2014 Business Plan for the Department of Health and
Social Services;
• 2013-2014 Business Plan for the Department of Finance.
The Main Estimates report (noted above) is presented annually
to the Legislative Assembly and represents the government’s
financial plan.
All data are subject to future revisions. 2013-2014 estimates are
based on total active physicians for the fiscal year.
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129
CHAPTER 3: northwest territories
Registered Persons
1. Number as of March 31st (#).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
47,544
43,639
44,216
42,786
41,158
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
27
27
27
27
27
74,628,142
69,613,271
83,425,969
72,850,737
74,345,948
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
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 ($).
not applicable
not applicable
not applicable
not applicable
not applicable
Public Facilities1
2. Number (#).
3. Payments for insured health services ($).1
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
1,104
1,102
1,113
1,196
1,049
12,307,400
14,775,269
15,418,029
17,564,725
15,390,929
11,588
10,611
11,657
11,725
11,068
3,473,274
3,526,527
4,089,648
4,041,670
4,135,160
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12. Total number of claims, out-patient (#).
13. Total payments, out-patient ($).
8
7
12
18
14
33,175
54,896
38,898
130,376
223,151
45
53
46
66
53
14,171
31,185
22,132
37,765
65,459
1. Payments for insured health services are estimated and include only those health services occurring within acute care facilities (i.e. hospitals that offer both in-patient and out-patient
services).
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canada health act – annual report 2013-2014
CHAPTER 3: northwest territories
Insured Physician Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
283
291
284
297
293
15. Number of opted-out physicians (#).
0
0
0
0
0
16. Number of non-participating physicians (#).
0
0
0
0
0
37,462,782
39,059,071
39,500,323
40,925,322
40,324,562
1,879,011
1,702,449
1,637,306
1,460,349
1,206,100
14. Number of participating physicians (#). 2
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18. Total payments for services provided by
physicians paid through fee-for-service ($).
Insured Physician Services Provided to Residents in Another Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
34,266
36,727
43,006
49,089
47,872
4,096,340
4,944,818
4,591,100
5,333,650
5,147,414
19. Number of services (#).
20. Total payments ($).
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
118
117
103
115
101
6,883
14,825
9,841
18,672
10,388
Insured Surgical-Dental Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
23. Number of participating dentists (#).
not available
not available
not available
not available
not available
24. Number of services provided (#).
not available
not available
not available
not available
not available
25. Total payments ($).
not available
not available
not available
not available
not available
2. Estimate based on total active physicians for each fiscal year.
canada health act – annual report 2013-2014
131
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canada health act – annual report 2013-2014
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2013-2014
Nunavut
Introduction
The Department of Health faces many unique challenges when
providing for the health and well-being of Nunavummiut. The
population of 35,5911 is approximately 82 percent Inuit, and 49
percent of the population is under the age of 25 years (17, 524
people)2. The territory is made up of 25 communities located
across three time zones and divided into three regions: the Baffin
(or Qikiqtaaluk), 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 2013-2014, the territorial operations and maintenance budget
for the Department of Health was $308,000,000, 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 (i.e. diagnostic services); therefore,
access to a range of hospital and specialist services often
requires that residents be sent out of the territory.
In 2013-2014 an additional $24,260,000 was allocated to the
Department for capital projects.4 The Department of Health
2013-2014 capital projects included: renovation of the Baffin
Regional Hospital and replacement of the Taloyoak Health
Centre.5
To enhance delivery of health services, social programs were
transferred to a new Department of Family Services on
April 1, 2013.
1.0 Public Administration
1.1Health 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 has 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.
In the winter of 2013, the Department amended the Medical
Care Act and Regulations under the Hospital Insurance and
Health and Social Services Administration Act so that members
of the Royal Canadian Mounted Police (RCMP) are now insured
members of the Nunavut Health Care Plan. The amendment
came into force April 1, 2013.
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
Nunavut Bureau of Statistics January 21, 2014 http://www.stats.gov.nu.ca/en/Population%20estimate.aspx
1
Nunavut Bureau of Statistics January 21, 2014 http://www.stats.gov.nu.ca/en/Population%20estimate.aspx
2
Department of Health, Division of Finance Freebalance Report
3
2013/2014 Capital Estimates, Government of Nunavut
4
2013/2014 Capital Estimates, Government of Nunavut
5
canada health act – annual report 2013-2014
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Insurance. 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.
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 November 28, 2013.
2.0Comprehensiveness
2.1 Insured Hospital Services
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 2013-2014.
In 2013-2014 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.
The Qikiqtani General Hospital (QGH) is currently the only acute
care facility in Nunavut providing a range of in- and out-patient
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.
As the two regional facilities in Rankin Inlet and Cambridge Bay
are able to recruit additional physicians, they will also be able
to offer a broader range of in-patient and out-patient 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. 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.
Other community health centres provide public health services,
out-patient services and urgent treatment services. The
Department also operates a Family Practice Clinic in Iqaluit.
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The clinic, established in 2006 with funding from the Primary
Health Care Transition Fund, 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 programs, such as a
Diabetes Clinic, and receives physician support via 2-3 physician
days per month. At present, the clinic is staffed by three nurse
practitioners.
The Department is responsible for authorizing, licensing,
inspecting and supervising all health facilities in the territory.
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.
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 Department makes the determination to add insured
services in its facilities 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 2013-2014 to the list of insured hospital services.
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 2013-2014. The Nursing Act allows for licensure of nurse
practitioners in Nunavut; this permits nurses to deliver insured
services in 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
CHAPTER 3: nunavut
main referral centres in Ottawa, Winnipeg, and Yellowknife.
Recruitment of full-time family physicians has improved
significantly and there are 26 family physician positions funded
through the Department, providing over 5,000 days of service
annually across the territory.
There are a total of 26 full-time family physician positions in
Nunavut (16 in the Baffin region; 7.5 in the Kivalliq region; 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. Physicians can make an election
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 20132014, no physicians provided written notice of this election.
All physicians practicing in Nunavut are under contract with the
Department.
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 2013-2014.
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 2013-2014
2.4 U
ninsured Hospital, Physician and
Surgical-Dental Services
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 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).
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 2013-2014 the Qikiqtani General Hospital charged a
$2,286 per diem rate for services provided for non-Canadian
resident stays.
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 under Portability). 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.
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3.0Universality
3.2 Other Categories of Individuals
3.1Eligibility
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.
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 2013-2014.
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 (e.g. 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.
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, 2014, 35,897 individuals were registered with the
Nunavut Health Care Plan, up by 856 from the previous year.
There are no formal provisions for Nunavut residents to opt out
of the Nunavut Health Care Plan.
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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.
4.2Coverage 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. No
legislative or regulatory changes were made in 2013-2014 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
CHAPTER 3: nunavut
Reciprocal Billing Agreements provide payment of in- and outpatient 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.
4.3Coverage 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 $2,286 per day and for outpatient care it is $287 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
the Inuit language 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 minor
ophthalmology, urology, orthopaedics, gynaecology, paediatrics,
general surgery, emergency trauma, ENT/otolaryngology and
dental surgery under general anesthesia. Patients requiring
specialized surgeries are sent to other jurisdictions. Diagnostic
services include: radiology, laboratory, electrocardiogram and
CT scans. Rehabilitative services are available in Iqaluit and
provided via contracted services in the Kivalliq and Kitikmeot.
Although nursing and other health professionals were not at full
capacity, all essential acute, public, dental, and mental health
services were provided in 2013-2014.
Outside of Iqaluit, out-patient and 24-hour emergency nursing
services are provided by local health centres in Nunavut’s 24
other communities. Telehealth services are available in all 25
communities in Nunavut. 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. Nunavut also has two
Continuing Care Centres located in Igloolik and Gjoa Haven.
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.
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 2013-2014 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.
For services and equipment unavailable in Nunavut, patients are
referred to other jurisdictions.
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137
CHAPTER 3: nunavut
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 either paid on a per-diem
basis or through fee-for-service.
5.3 Payments to Hospitals
Funding for the Qikiqtani General Hospital, regional health
facilities and community health centres is provided through the
Government of Nunavut’s budget process.
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6.0Recognition Given to
Federal Transfers
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 2013-2014, they included:
• 2013-2014 Budget Address; and
• 2014-2017 Government of Nunavut Business Plan.
CHAPTER 3: nunavut
Registered Persons
1. Number as of March 31st (#).6
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
33,540
35,515
35,893
35,041
35,897
Insured Hospital Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
28
28
28
28
28
not available
not available
not available
not available
not available
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
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
Public Facilities
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 ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
2,890
2,924
3,406
3,313
3,360
30,013,566
28,527,577
38,486,274
39,244,449
37,494,619
18,270
18,352
22,725
21,686
22,113
5,985,808
6,318,885
8,975,802
7,780,896
8,297,900
Insured Hospital Services Provided Outside Canada
10. Total number of claims, in-patient (#).
0
0
0
1
1
11. Total payments, in-patient ($).
0
0
0
4,410
20,574
12. Total number of claims, out-patient (#).
0
0
0
0
20
13. Total payments, out-patient ($).
0
0
0
0
20,041
6. The difference in the number of registered Nunavut residents and those covered under the Nunavut Health Care Plan is due to delays in the reconciliation of data on residents who
have left the territory.
canada health act – annual report 2013-2014
139
CHAPTER 3: nunavut
Insured Physician Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
225
225
375
409
349
15. Number of opted-out physicians (#).
0
0
0
0
0
16. Number of non-participating physicians (#).
0
0
0
0
0
not available
not available
not available
not available
not available
300,980
312,786
334,539
403,418
348,473
14. Number of participating physicians (#).
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18. Total payments for services provided by
physicians paid through fee-for-service ($).7
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20. Total payments ($).
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
72,065
73,564
75,108
80,311
80,682
5,585,067
5,901,962
6,393,341
6,341,047
6,855,743
Insured Physician Services Provided Outside Canada
21. Number of services (#).
22. Total payments ($).
17
53
22
15
82
4,848
1,575
963
732
7,346
Insured Surgical-Dental Services Within Own Province or Territory
2009–2010
2010–2011
2011–2012
2012–2013
2013–2014
23. Number of participating dentists (#).
not available
not available
not available
not available
not available
24. Number of services provided (#).
not available
not available
not available
not available
not available
25. Total payments ($).
not available
not available
not available
not available
not available
7. Typically, Nunavut does not pay its physicians through fee-for-service. Instead, the majority of physicians are compensated through contracted salaries.
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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 2013-2014
141
142
canada health act – annual report 2013-2014
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 2013-2014
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 ».
canada health act – annual report 2013-2014
Codifications
comme élément
de preuve
Incompatibilité
— lois
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;
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
canada health act – annual report 2013-2014
145
Canada Health — July 8, 2012
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.
Short title
1. Loi canadienne sur la santé.
Titre abrégé
1984, ch. 6, art. 1.
1984, c. 6, s. 1.
INTERPRETATION
DÉFINITIONS
2. In this Act,
Definitions
“Act of 1977” [Repealed, 1995, c. 17, s. 34]
“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;
“cash
contribution”
« contribution
pécuniaire »
“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,
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.
« contribution » [Abrogée, 1995, ch. 17, art. 34]
(c) home care service, and
(d) ambulatory health care service;
146
“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;
canada health act – annual report 2013-2014
« 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;
(b) adult residential 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.
2
« 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”
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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canada health act – annual report 2013-2014
147
Canada Health — July 8, 2012
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.
canada health act – annual report 2013-2014
« 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.
148
« 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.
Ne sont pas compris parmi les services hospitaliers les services exclus par les règlements.
4
« 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”
Santé — 8 juillet 2012
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;
5
canada health act – annual report 2013-2014
Règle générale
149
Canada Health — July 8, 2012
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.
1984, ch. 6, art. 10.
150
canada health act – annual report 2013-2014
6
Universalité
Santé — 8 juillet 2012
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
7
canada health act – annual report 2013-2014
Consentement
préalable à la
prestation des
services de santé
assurés
facultatifs
151
Canada Health — July 8, 2012
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 :
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.
(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 :
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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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;
Reasonable
compensation
Définition de
« services de
santé assurés
facultatifs »
8
Rémunération
raisonnable
Santé — 8 juillet 2012
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 :
9
Étapes de la
consultation
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153
Canada Health — July 8, 2012
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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10
Santé — 8 juillet 2012
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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Canada Health — July 8, 2012
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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12
Santé — 8 juillet 2012
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
13
Rapport annuel
du ministre
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157
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.
158
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14
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 2013-2014
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.
canada health act – annual report 2013-2014
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
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 Interpretations 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 insured
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services generally encompasses medically required services rendered by licensed medical practitioners as well as surgical-dental
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.
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Annex b: policy interpretation letters
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.
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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Annex b: policy interpretation letters
[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 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.
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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.
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.
Where dispute avoidance activities prove unsuccessful, dispute
resolution activities may be initiated, beginning with governmentto-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.
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.
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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Annex c: dispute avoidance and resolution process under the canada health act
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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Annex c: dispute avoidance and resolution process under the canada health 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.
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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Annex c: dispute avoidance and resolution process under the canada health act
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:
• p articipate actively in ad hoc federal/provincial/territorial
committees on Canada Health Act issues; and
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.
• W
ithin 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.
• T
he panel will assess the issue in dispute in accordance with
the provisions of the Canada Health Act, will undertake factfinding and provide advice and recommendations.
• T
he panel will then report to the governments involved on the
issue within 60 days of appointment.
Health Canada commits to provide advance assessments to any
province or territory upon request.
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.
Dispute Resolution
Public Reporting
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 noncompliance provisions of the Act.
Governments will report publicly on Canada Health Act dispute
avoidance and resolution activities, including any panel report.
• u ndertake government-to-government information exchange,
discussions and clarification on issues as they arise.
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.
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canada health act – annual report 2013-2014
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, Healthy Living and Seniors
300 Carlton Street
Winnipeg, MB R3B 3M9
1-800-392-1207
www.manitoba.ca/health
Prince Edward Island
Saskatchewan Health
3475 Albert Street
Regina, SK S4S 6X6
1-800-667-7766
www.health.gov.sk.ca
Department of Health and Wellness
P.O. Box 2000
Charlottetown, PE C1A 7N8
(902) 368-6414
www.gov.pe.ca/health
Nova Scotia
Department of Health and Wellness
P.O. Box 488
Halifax, NS B3J 2R8
(902) 424-5818
1-800-387-6665 (toll-free in Nova Scotia)
1-800-670-8888 (TTY/TDD)
www.novascotia.ca/DHW
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
Saskatchewan
Alberta
Alberta Health
P.O. Box 1360, Station Main
Edmonton, AB T5J 1S6
(780) 638-3228
www.health.alberta.ca
British Columbia
Ministry of Health
1515 Blanshard Street
Victoria, BC V8W 3C8
Toll free in B.C.: 1-800-465-4911
In Victoria: (250) 952-1742
www.gov.bc.ca/health
Yukon
Health and Social Services H-2
Box 2703
Whitehorse, YT Y1A 2C6
1-867-667-5209
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 1-867-777-7413
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/
Public A dministration
A ccessibility
Univ ersality
Comprehensiv eness
Portability
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