CANADA HEALTH ACT LOI CANADIENNE SUR LA SANTÉ 2012–2013 2012

CANADA HEALTH ACT LOI CANADIENNE SUR LA SANTÉ 2012–2013 2012
CANADA HEALTH ACT
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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 2012–2013
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 2012-2013
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, 2013
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: 130413
Cat.: H1-4/2013E-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
Saskatchewan Health
Alberta Health
British Columbia Ministry of Health
Yukon Department of 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 unit, the translators, editors and concordance experts, and staff of Health Canada at headquarters and in
the regional offices.
Canada Health Act — Annual Report 2012–2013
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Canada Health Act — Annual Report 2012–2013
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 2012–2013_____________________________________ 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
Canada Health Act — Annual Report 2012–2013
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Canada Health Act — Annual Report 2012–2013
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.
The roles and responsibilities for Canada’s health care system
are shared between the federal and provincial or territorial
Canada Health Act — Annual Report 2012–2013
governments. The provincial and territorial governments
have primary jurisdiction in the administration and delivery
of health care services. This includes setting their own priorities, administering their health care budgets and managing
their own resources. The federal government, under the
Canada Health Act, sets out the criteria and conditions that
must be satisfied by the provincial and territorial health
insurance plans for provinces and territories to qualify for
their full share of the cash contribution available to them
under the federal Canada Health Transfer.
On an annual basis, the federal Minister of Health is required
to report to Parliament on the administration and operation
of the Canada Health Act, as set out in section 23 of the Act.
The vehicle for so doing is the Canada Health Act Annual
Report. While the principal and intended audience for
this report is Parliamentarians, it is a public document that
offers a comprehensive report on insured health services in
each of the provinces and territories. The annual report is
structured to address the mandated reporting requirements
of the Act; as such, its scope does not extend to commenting
on the status of the Canadian health care system as a whole.
Provincial and territorial health care insurance plans
generally respect the criteria and conditions of the Canada
Health Act and many exceed the requirements of the Act.
However, when instances of possible non-compliance with
the Act arise, Health Canada’s approach to the administration of the Act emphasizes transparency, consultation
and dialogue with provincial and territorial health care
ministries. The application of financial penalties through
deductions under the Canada Health Transfer is considered
only as a last resort when all other options to resolve an
issue collaboratively have been exhausted. Pursuant to the
commitment made by premiers under the 1999 Social Union
Framework Agreement, federal, provincial and territorial
governments (except Quebec) agreed through an exchange
of letters, in April 2002, to a Canada Health Act Dispute
Avoidance and Resolution (DAR) process. The DAR process was formalized in the First Ministers’ 2004 Accord.
Although the DAR process includes dispute resolution
provisions, the federal Minister of Health retains the final
authority to interpret and enforce the Canada Health Act.
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Canada Health Act — Annual Report 2012–2013
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 from former federal Minister, 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
Canada have reasonable access to medically necessary services on a prepaid basis, without charges directly related to
the provision of insured health services.
Key Definitions Under the Canada Health Act
Insured persons are eligible residents of a province or terri­
tory. 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.
Prior to June 29, 2012, serving members of the RCMP were
also excluded from the definition of insured persons under
the Act but the Jobs, Growth and Long-term Prosperity Act
amended the Canada Health Act and repealed that exclusion.
Canada Health Act — Annual Report 2012–2013
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
therefore 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;
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Chapter 1: Canada Health Act Overview
• two conditions that apply to insured health services and
extended health care services; and
• extra-billing and user charges provisions that apply only
to insured health services.
The Criteria
1. Public Administration (section 8)
The public administration criterion requires provincial and
territorial health care insurance plans to be administered
and operated on a non-profit basis by a public authority,
which is accountable to the provincial or territorial government for decision-making on benefit levels and services, and
whose records and accounts are publicly audited. However,
the criterion does not prevent the public authority from
contracting out the administration of 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)
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.
4
Residents who are temporarily absent from their home
province or territory or from Canada, must continue to
be covered for insured health services during their absence.
If insured persons are temporarily absent in another province
or territory, the portability criterion requires that insured
services be paid at the host province’s rate. If insured persons
are temporarily out of the country, insured services are to be
paid at the home province’s rate.
The portability criterion does not entitle a person to seek
services in another province, territory or country, but is
intended to permit a person to receive necessary services
in relation to an urgent or emergent need when absent on
a temporary basis, such as on business or vacation.
Prior approval by the health care insurance plan in a person’s home province or territory may be required before
coverage is extended for elective (non-emergency) services
to a resident while temporarily absent from his/her province
or territory.
5. Accessibility (section 12)
The intent of the accessibility criterion is to ensure that
insured persons in a province or territory have reasonable access to insured hospital, medical and surgical-dental
services on uniform terms and conditions, unprecluded or
unimpeded, either directly or indirectly, by charges (user
charges or extra-billing) or other means (e.g., discrimination
on the basis of age, health status or financial circumstances).
Reasonable access in terms of physical availability of
medically necessary services has been interpreted under
the Canada Health Act using the “where and as available”
rule. Thus, residents of a province or territory are entitled
to have access on uniform terms and conditions to insured
health services at the setting “where” the services are provided and “as” the services are available in that setting.
In addition, the health care insurance plans of the province
or territory must provide:
• reasonable compensation to physicians and dentists
for all the insured health services they provide; and
• payment to hospitals to cover the cost of insured
health services.
The Conditions
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.
Canada Health Act — Annual Report 2012–2013
Chapter 1: Canada Health Act Overview
2. Recognition (section 13(b))
Other Elements of the Act
The provincial and territorial governments are required
to recognize the federal financial contributions toward
both insured and extended health care services.
Regulations (section 22)
Extra-billing and User Charges
The provisions of the Canada Health Act pertaining to
extra-billing 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.
Extra-billing (section 18)
Under the Act, extra-billing is defined as the billing for an
insured health service rendered to an insured person by a
medical practitioner or a dentist (i.e., a dentist providing
insured surgical-dental services in a hospital setting) in an
amount in addition to any amount paid or to be paid for
that service by the health care insurance plan of a province
or territory. For example, if a physician was to charge a
patient any amount for an office visit that is insured by the
provincial or territorial health insurance plan, the amount
charged would constitute extra-billing. Extra-billing is seen
as a barrier or impediment for people seeking medical care,
and is therefore also contrary to the accessibility criterion.
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.
Canada Health Act — Annual Report 2012–2013
Section 22 of the Canada Health Act enables the federal
government to make regulations for administering the Act
in the following areas:
• defining the services included in the Act’s definition of
“extended health care services,” i.e., nursing home care
or home care;
• prescribing which services are excluded from hospital
services;
• prescribing the types of information that the federal
Minister of Health may reasonably require, as well as the
format and submission deadline for the information; and
• prescribing how provinces and territories are required
to recognize the CHT in their documents, advertising
or promotional materials.
To date, the only regulations in force under the Act are the
Extra-billing and User Charges Information Regulations.
These regulations require the provinces and territories to
provide estimates of extra-billing and user charges before
the beginning of a fiscal year. They also require financial
statements approximately two years after the fiscal year
ends showing the amounts actually charged. (A copy of
these regulations is provided in Annex A).
Penalty Provisions of the Canada Health Act
Mandatory Penalty Provisions
Under the Act, provinces and territories that allow
extra-billing and user charges are subject to mandatory
dollar-for-dollar deductions from the federal transfer
payments under the CHT. This means that when it has
been determined that a province or territory has allowed,
for example, extra-billing by physicians in an amount
of $500,000, the federal CHT cash contribution to that
province or territory will be reduced by that same amount.
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.
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Chapter 1: Canada Health Act Overview
Excluded Services and Persons
Although the Canada Health Act requires that insured
health services be provided to insured persons in a manner
that is consistent with the criteria and conditions set out in
the Act, not all Canadian residents or health services fall
under the scope of the Act.
Excluded Services
A number of services provided by hospitals and physicians
are not considered medically necessary, and thus are not
insured under provincial and territorial health insurance
legislation. Uninsured hospital services for which patients
may be charged include preferred hospital accommodation
unless prescribed by a physician, 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., refugee claimants) 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. Prior to June 29, 2012,
serving members of the RCMP were also excluded from the
definition of insured persons under the Act but the Jobs,
Growth and Long-term Prosperity Act amended the Canada
Health Act and repealed that exclusion.
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.
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There is a Frequently Asked Questions link on Health
Canada’s web-site to address common concerns that
Canadians might have about Canada’s publicly-funded
health insurance plans.
See: http://hc-sc.gc.ca/hcs-sss/medi-assur/faq-eng.php
Policy Interpretation Letters
There are two key policy statements that clarify the federal
position on the Canada Health Act. These statements were
made in the form of ministerial letters from former federal
ministers of health to their provincial and territorial counterparts. Both letters are reproduced in Annex B of this report.
Epp Letter
In June 1985, approximately one year following the passage of
the Canada Health Act in Parliament, then-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
Canada Health Act — Annual Report 2012–2013
Chapter 1: Canada Health Act Overview
Act includes any public facility that provides acute, rehabilitative or chronic care. Thus, when a provincial or territorial
health insurance plan pays the physician fee for a medically
necessary service delivered at a private clinic, it must also
pay the facility fee or face a deduction from federal transfer
payments.
Dispute Avoidance and Resolution Process
In April 2002, then-federal Minister of Health A. Anne
McLellan outlined in a letter to her provincial and territorial
counterparts a Canada Health Act Dispute Avoidance and
Resolution process, which was agreed to by provinces and
territories, except Quebec. The process meets federal and
provincial or territorial interests of avoiding disputes related
to the interpretation of the principles of the Act and, when
this is not possible, resolving disputes in a fair, transparent
and timely manner.
The process includes the dispute avoidance activities of
government-to-government information exchange; discussions and clarification of issues as they arise; active
participation of governments in ad hoc federal/provincial/
territorial committees on Act-related issues; and Canada
Health Act advance assessments, upon request.
Where dispute avoidance activities prove unsuccessful, dispute resolution activities may be initiated, beginning with
government-to-government fact-finding and negotiations.
If these are unsuccessful, either minister of health involved
may refer the issues to a third-party panel to undertake
fact-finding and provide advice and recommendations.
The federal Minister of Health has the final authority to
interpret and enforce the Canada Health Act. In deciding
whether to invoke the non-compliance provisions of the Act,
the Minister will take the panel’s report into consideration.
A copy of Minister McLellan’s letter is included in Annex C
of this report.
Evolution of Federal Health
Care Transfers
Grants To Help Establish Programs and Cost-Sharing
Federal support for provincial health care goes back to the
late 1940s when the National Health Grants were created.
These grants were considered to be essential building blocks
of a national health care system. While the grants were
mainly used to build up the Canadian hospital infrastructure,
they also supported initiatives in areas such as professional
training, public health research, tuberculosis control and
cancer treatment. By the mid-1960s, the grants available to
the provinces totalled more than $60 million annually.
Canada Health Act — Annual Report 2012–2013
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 early December 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 Hospital Insurance
and Diagnostic Services Act (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
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Chapter 1: Canada Health Act Overview
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.
Budget legislation provided for total CHST amounts
(cash and tax transfers) for the following years, with an
annual floor of $11 billion for the cash component to
apply until 2002–2003.
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 (EPF) “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 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 CHA, subject only to
the conditions of providing information and recognizing the
federal transfer, as set out in section 13 of the CHA.
The EPF Act also included a new transfer for the Extended
Health Care Services Program. This group of health care
services, defined as nursing home intermediate care, adult
residential care, ambulatory health care and the health
aspects of home care, were block funded on the basis of
$20 per capita for fiscal year 1977–1978, and subject to
the same escalator as insured health services. This portion
of the EPF transfer was made on a virtually unconditional
basis and, unlike the insured services transfer, was not
subject to specified program delivery criteria.
Under the prevailing legislative framework, the Government
of Canada was required to withhold all of the monthly health
care transfer to a province or territory for each month the
program delivery criteria were not met. It was not until the
enactment of the Canada Health Act in 1984 that special
deduction provisions came into force allowing for dollarfor-dollar deductions for extra-billing and user charges, and
discretionary deductions when provincial and territorial
plans failed to fully comply with other provisions set out in
the Act. These criteria and conditions remain in force to
the present day.
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
8
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;
• determining the amounts of any deductions pursuant
to the extra-billing and user charges provisions of the
Act; and
• communicating all of these amounts 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.
Canada Health Act — Annual Report 2012–2013
Chapter 1: Canada Health Act Overview
In 2003, the government committed $36.8 billion over
five years to support priority areas of health reform (primary care, home care and catastrophic drugs). This was
provided through $14 billion in increased CHST transfers
and $16 billion for the Health Reform Transfer, as well as
$1.5 billion for medical equipment. This was in addition to
$5.3 billion in federal direct spending on health information
technologies, Aboriginal health initiatives, patient safety
and other health-related federal initiatives.
The federal government also agreed to restructure the
CHST to enhance the transparency and accountability
of federal support for health.
The Canada Health Transfer
The CHST was restructured into two new transfers,
the Canada Health Transfer (CHT) and Canada Social
Transfer (CST), effective April 1, 2004. The CHT supports the Government of Canada’s ongoing commitment
to maintain the national criteria and conditions of the
Canada Health Act. The CST; a block fund that supports
post-secondary education and social assistance and social
services, continues to give provinces and territories the
flexibility to allocate funds among these social programs
according to their respective priorities.
The existing CHST-legislated amounts were apportioned
between the new transfers, with the percentage of cash and
tax points allocated to each transfer reflecting provincial
and territorial spending patterns among the areas supported
by the transfers: 62 percent for the CHT and 38 percent for
the CST.
2004 10-year Plan to Strengthen Health Care
Federal transfers to the provinces and territories were further increased as a result of the 10-Year Plan to Strengthen
Health Care. Signed by all first Ministers on September 16,
2004, this initiative committed the Government of Canada
to an additional $41.3 billion in funding, over ten years until
2013–2014, to the provinces and territories for health. This
included $35.3 billion in increases to the CHT, $5.5 billion in
Wait Times Reduction funding, and $500 million in support
of diagnostic and medical equipment.
Canada Health Act — Annual Report 2012–2013
Budget 2007
To restore fiscal balance in Canada, Budget 2007 put all
major transfers on a long-term, principles-based track to
2013–2014. In order to provide comparable treatment
for all Canadians, regardless of where they live the budget
legislated equal per capita cash support for the CST, starting
in 2007–2008, and the CHT, starting after the 10-Year
Plan to Strengthen Health Care concludes in 2013–2014.
In addition, Budget 2007 invested an additional $1 billion to help provinces and territories introduce wait time
guarantees, including initiatives delivered through Canada
Health Infoway.
Recent Transfer Changes
As announced by the Government of Canada in
December 2011, and legislated in the Jobs, Growth
and Long-term Prosperity Act, the CHT will continue
to grow at an annual rate of 6 percent for an additional
three years beyond 2013–2014 (i.e., until 2016–2017).
Starting in 2017–2018, the CHT will grow in line with
a three-year moving average of nominal gross domestic
product growth, with funding guaranteed to increase by
at least three per cent 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
9
10
Canada Health Act — Annual Report 2012–2013
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:
• monitoring and analysing provincial and territorial
health insurance plans for compliance with the criteria,
conditions and extra-billing and user charges provisions
of the Act;
• disseminating information on the Act and on publicly
funded health care insurance programs in Canada;
• responding to inquiries about the Act and health insur-
ance issues received by telephone, mail and the Internet,
from the public, members of Parliament, government
departments, stakeholder organizations and the media;
• developing and maintaining formal and informal
partnerships with health officials in provincial and
territorial governments for information sharing;
• developing and producing the Canada Health Act Annual
Report on the administration and operation of the Act;
• conducting issue analysis and policy research to provide
policy advice;
• collaborating with provincial and territorial health
department representatives through the Interprovincial
Health Insurance Agreements Coordinating Committee
(see below);
• working 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
non-compliance and recommending appropriate action
to resolve the issue.
Canada Health Act — Annual Report 2012–2013
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.
RCMP Coverage
On June 28, 2012, the Jobs, Growth and Long-term
Prosperity Act amended the Canada Health Act to remove
members of the RCMP from the list of persons excluded
from the definition of insured person under the Canada
Health Act. As a result, effective April 1, 2013, responsibility for health insurance plan coverage for RCMP
members was transferred from the federal government
to the provinces and territories.
While the RCMP, and not Health Canada, was the federal
department responsible for this transition, this issue was
discussed by the Eligibility and Portability Agreement
11
Chapter 2: Administration and Compliance
Working Group (EPAWG), which is a working group of the
Interprovincial Health Insurance Agreements Coordinating
Committee (IHIACC). Through its Secretariat support of the
EPAWG, the Canada Health Act Division provided guidance
to two provinces to help resolve an eligibility issue involving
an RCMP member who moved from one province to
another at the time of health insurance coverage transition.
Federal Interim Health Program
On June 30, 2012, changes to the eligibility criteria and
benefits available under the Interim Federal Health Program
for refugee claimants came into effect. While this program
falls under the jurisdiction of Citizenship and Immigration
Canada (CIC), not Health Canada, this issue was discussed
by the Eligibility and Portability Agreement Working Group
(EPAWG), to clarify these changes. Health Canada provided
the EPAWG assistance in liaising with the appropriate contacts in CIC.
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 non-compliance 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.
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, deductions were taken from
the March 2013 Canada Health Transfer (CHT) payments
to British Columbia and Newfoundland and Labrador.
On the basis of their health ministry’s report to Health
Canada, deductions were taken from the March 2013
CHT payments of Newfoundland and Labrador in respect
of extra-billing and user charges for insured surgical-dental
services in the amount of $50,757.74.
Deductions in the amount of $280,019 were taken from
the March 2013 CHT payments of British Columbia in
respect of extra-billing and user charges for insured health
services at private clinics. This amount was estimated by the
federal Minister of Health under section 20 of the CHA 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.
Health Canada continues to pursue provincial and territorial
compliance with the CHA. The following paragraphs provide a description of some key developments since the last
Canada Health Act Annual Report.
In January 2011, the Vancouver General Hospital in British
Columbia began charging patients a fee when they elect to
have robot-assisted surgery versus the conventional surgical
alternative for certain medically necessary procedures (e.g.,
prostatectomy, hysterectomy). During 2012–2013, Health
Canada continued to examine the CHA implications of
patient charges for these robot-assisted surgeries.
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 March 2011, Health Canada learned of an Alberta
surgeon who had charged a fee to an individual for the
provision of an insured service. Health Canada contacted
Alberta Health officials to ask them to investigate the
issue. Alberta Health agreed and, following their review,
requested that the surgeon reimburse the individual for
the extra-billed amount. In September 2012, Health
Canada received confirmation that the individual was
fully reimbursed and the extra-billing issue had been
successfully resolved.
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
During 2012–2013, Health Canada made inquiries to
Alberta Health regarding private primary health care
clinics in Alberta which charge patients annual enrollment
and membership fees. Typically, the fees cover a basket
of uninsured services but also promise quick access and
unrushed appointments with family physicians. Alberta
Health informed Health Canada that the Ministry would
12
Canada Health Act — Annual Report 2012–2013
Chapter 2: Administration and Compliance
be undertaking a formal compliance investigation in 2013
to ensure that clinics that are charging membership fees are
operating in compliance with provincial and federal legislation. If the receipt of insured services was conditional upon
the payment of fees, this would pose concerns under the
accessibility criterion of the Act.
On February 26, 2012, a public inquiry into the possibility
of improper preferential access to publicly funded health
services in Alberta was announced. Following the appointment of Justice John Z. Vertes as Commissioner, in March
2012, public hearings were held as part of the Alberta
Health Services Preferential Access Inquiry, starting in
December 2012 in Edmonton and ending in April 2013 in
Calgary. The final report of the Inquiry, released in August
2013, found no evidence of systemic preferential access to
care. However, some isolated incidents of improper preferential access were found by the Inquiry. In addition,
the report highlighted a number of practices that could
open up avenues for improper preferential access and
makes recommendations to discourage improper access
in the future. The Inquiry’s recommendations have been
accepted by Alberta Health and work is underway on
their implementation.
In June 2012, the Discipline Committee of the College of
Physicians and Surgeons of Ontario found that an Ontario
doctor’s membership fee to join the doctor’s practise failed
to comply with their policy on Block Fees and Uninsured
Services. In July 2012, Health Canada contacted Ministry of
Health and Long-Term Care (MOHLTC) officials to express
concerns over these findings and to enquire if refunds would
be given to patients who were inappropriately charged. In
August 2012, MOHLTC officials responded that they had
advised the doctor of the potential violation of Ontario’s
Commitment to the Future of Medicare Act (CFMA) and
counselled the doctor to correct the practices of the clinic.
In March 2012, the Standing Senate Committee on Social
Affairs, Science and Technology released a report on the 2004
Health Accord which stated that 37.1% of patients who
had a colonoscopy in a non-hospital setting were charged
to access the service. These findings were based on a 2009
survey of Ontario residents who had a colonoscopy in the
previous 10 years. After initial research, Health Canada contacted MOHLTC officials in April 2012 to express concerns
that some endoscopy clinics were advertising block fees (a fee
charged for a package of uninsured services) in such a way
as to suggest they were compulsory. MOHLTC responded
that from 2006 to 2009 16 investigations occurred and
8 contraventions of the CFMA were found which resulted
in a total of $82,628.75 in reimbursements to 1,634 patients.
For the period from January 1, 2010 to March 31, 2013,
8 investigations were ongoing. Health Canada continues
to monitor this situation.
In November 2012, a working group on health co-ops was
commissioned by Quebec Health Minister, Réjean Hébert.
The working group’s report was released on August 1, 2013
Canada Health Act — Annual Report 2012–2013
at which time the minister agreed to take measures, including
legislative amendments, to establish better guidelines for
health co-ops. The working group found many benefits to
health co-operatives but cautioned that there were concerns
when members were required to pay fees in order to access
insured health services. If receipt of insured services were
conditional upon the payment of co-op membership fees,
this would pose concerns under the accessibility criterion
of the Act.
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 extrabilling 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,
13
Chapter 2: Administration and Compliance
$2,025,000 was deducted from British Columbia’s cash
contribution for extra-billing that occurred in the province
between 1992–1993 and 1995–1996. These deductions
were non-refundable, as were all subsequent deductions.
In January 1995, then 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 communi­
cation 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
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 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
14
of $8,121 was made to Nova Scotia’s March 2006 CHT
payment to reconcile amounts actually charged in respect
of extra-billing and user charges with the penalties that had
already been levied based on provincial estimates reported
for fiscal 2003–2004.
In January 2003, British Columbia provided a financial statement in accordance with the Canada Health Act Extra-billing
and User Charges Information Regulations, indicating aggregate amounts actually charged with respect to extra-billing
and user charges during fiscal year 2000–2001, totalling
$4,610. Accordingly, a deduction of $4,610 was made to
the March 2003 CHST cash contribution.
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, $786,940 in cash transfer deductions have
been taken from British Columbia’s CHT payments on the
basis of 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 $113,014 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. Deductions for each year
are detailed in a table following this passage.
Since the passage of the Canada Health Act, from April
1984 to March 2013, deductions totalling $9,657,007
have been applied against provincial cash contributions
in respect of the extra-billing and user charges provisions
of the Act. This amount excludes deductions totalling
$244,732,000 that were made between 1984 and 1987
and subsequently refunded to the provinces when extrabilling and user charges were eliminated.
Canada Health Act — Annual Report 2012–2013
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
Total
1,982,000
2,709,000
2,022,000
771,000
703,950
18,540
57,804
335,301
15,662
133,894
Province/
Territory
2004–2005
2005–2006
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
Total
1,100
0
0
0
0
0
3,577
58,679
50,758
394,544
11x
NL
PEI
0
0
0
0
0
0
0
0
0
0
NS
5,463
(8,121)
9,460
0
0
0
0
0
0
378,937
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
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
3,585,000
BC
72,464
29,019
114,850
42,113
66,195
73,925
75,136
33,219
280,019
2,943,325
YK
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
79,027
20,898
124,310
42,113
66,195
73,925
78,713
91,898
330,777
9,657,007
NU
Total
Understanding This Chart
• Under the Extra-billing and User Charges Information Regulations of the Canada Health Act, provinces and territories provide estimates of anticipated
extra-billing and user charges before the beginning of each fiscal year. They also provide financial statements approximately two years after the fiscal year
ends showing the amounts actually charged.
• 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 2012–2013
15
16
Canada Health Act — Annual Report 2012–2013
CHAPTER 3
PROVINCIAL AND TERRITORIAL HEALTH
CARE INSURANCE PLANS IN 2012–2013
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 2012–2013.
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 2012–2013:
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
2012–2013 was launched late spring 2013 with bilateral
teleconferences with each jurisdiction. An updated User’s
Guide was also sent to the provinces and territories at
that time.
Canada Health Act — Annual Report 2012–2013
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, 2013. 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.
17
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
Organization of the Information
Information in the tables is grouped according to the nine
subcategories described below.
Registered Persons: Registered persons are the number of
residents registered with the health care insurance plans
of each province or territory.
Insured Hospital Services Within Own Province or
Territory: Statistics in this sub-section relate to the provision
of insured hospital services to residents in each province or
territory, as well as to visitors from other regions of Canada.
Insured Hospital Services Provided to Residents in Another
Province or Territory: This sub-section presents out-ofprovince or out-of-territory insured hospital services that
are paid for by a person’s home jurisdiction when they
travel to other parts of Canada.
Insured Physician Services Within Own Province or
Territory: Statistics in this sub-section relate to the provision
of insured physician services to residents in each province or
territory, as well as to visitors from other regions of Canada.
Insured Physician Services Provided to Residents in Another
Province or Territory: This sub-section reports on physician
services that are paid by a jurisdiction to other provinces or
territories for their visiting residents.
Insured Physician Services Provided Outside Canada:
Physician services provided out of country represent residents’ medical costs incurred while travelling outside of
Canada that are paid by their home province or territory.
Insured Surgical-Dental Services Within Own Province
or Territory: The information in this subsection describes
insured surgical-dental services provided in each province
or territory.
Insured Hospital Services Provided Outside Canada:
Hospital services provided out of country represent residents’
hospital costs incurred while travelling outside of Canada
that are paid for by their home province or territory.
18
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
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 and administrators.
Budget 2012–2013 “A Sound Plan, A Secure Future,” provides
$2.9 billion in health spending which includes $227 million
over three years to design and start construction of a new acute
care facility in Corner Brook as well as funding to increase
access to health services and treatments, and to undertake
clinical efficiency and management reviews.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and Public Authority
Health care insurance plans managed by the Department
of Health and Community Services include the Hospital
Insurance Plan and the Medical Care Plan (MCP). Both
plans are non-profit and publicly administered.
The Hospital Insurance Agreement Act is the legislation
that enables the Hospital Insurance Plan. The Act gives the
Minister of Health and Community Services the authority
to make regulations for providing insured services on
uniform terms and conditions to residents of the province
under the conditions specified in the Canada Health Act
and its regulations.
The Medical Care Insurance Act, 1999 empowers 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,
Canada Health Act — Annual Report 2012–2013
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 legislative amendments to the Medical Care
Insurance Act, 1999 or the Hospital Insurance Agreement
Act in 2012–2013.
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 Estimates Committee 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 (2006), the Department of Health
and Community Services and the 13 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 2012–2013 Department of Health and Community
Services Annual Report was tabled in the House of
Assembly on September 30, 2013.
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. The Auditor
General has full and unrestricted access to 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 under the terms of the Public Tender Act.
Review engagements, compliance audits and physician audits
19
Chapter 3: Newfoundland and Labrador
were carried out by personnel from the Department under the
authority of the Medical Care Insurance Act, 1999. Physician
records and professional medical corporation records were
reviewed to ensure that the records supported the services
billed and that the services are insured under the MCP.
Beneficiary audits were performed by personnel from the
Department under the Medical Care Insurance Act, 1999.
Individual providers are randomly selected on a bi-weekly
basis for audit.
2.0 COMPREHENSIVENESS
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 outpatients 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 2012–2013.
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;
• the Medical Care Insurance Beneficiaries and Inquiries
Regulations; and
• the Physicians and Fee Regulations.
In 2012–2013 there were 1,155 physicians registered in the
province.
20
For purposes of the Act, the following services are covered:
• all services properly and adequately provided by physi-
cians to beneficiaries suffering from an illness requiring
medical treatment or advice;
• group immunizations or inoculations carried out by
physicians at the request of the appropriate authority; and
• diagnostic and therapeutic x-ray and laboratory ser-
vices 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, 2013 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, including the provincial medical association and the public. Laser treatment
of telangiectasia was de-insured as of March 1, 2013.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Newfoundland and Labrador
2.3 Insured Surgical-Dental Services
• any services rendered by a physician to the spouse and
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 Surgical-Dental Services Schedule.
• any service to which a beneficiary is entitled under an
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, 2013, there were no
opted-out dentists.
• the time taken or expenses incurred in travelling to
Because the Surgical-Dental Program is a component of the
MCP, management of the program is linked to the MCP process regarding changes to the list of insured services.
Addition of a surgical-dental service to the list of insured
services must be approved by the Minister.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Hospital services not covered by MCP include: preferred
accommodation at the patient’s request; cosmetic surgery
and other services deemed to be medically unnecessary;
ambulance or other patient transportation before admission or upon discharge; private duty nursing arranged by
the patient; non-medically required x-rays or other services
for employment or insurance purposes; drugs (except antirejection 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:
children of the physician;
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;
consult a beneficiary;
• ambulance service and other forms of patient
transportation;
• acupuncture and all procedures and services related to
acupuncture, excluding an initial assessment specifically
related to diagnosing the illness proposed to be treated
by acupuncture;
• examinations not necessitated by illness or at the request
of a third party except as specified by the Department;
• plastic or other surgery for purely cosmetic purposes,
unless medically indicated;
• laser treatment of telangiectasia;
• testimony in a court;
• visits 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;
• sex reassignment surgery, when not recommended by the
Clarke Institute of Psychiatry;
• any advice given by a physician to a beneficiary by
• in vitro fertilization and OSST (ovarian stimulation and
• the dispensing by a physician of medicines, drugs or
• reversal of previous sterilization procedure;
• surgical, diagnostic or therapeutic procedures provided in
telephone;
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;
sperm transfer);
facilities as of January 1998 other than those listed in the
Schedule to the Hospitals Act or approved by the appropriate authority under paragraph 3(d) of the Act; and
• other services not within the ambit of section 3 of
the Act.
Canada Health Act — Annual Report 2012–2013
21
Chapter 3: Newfoundland and Labrador
The majority of diagnostic services (e.g., laboratory services
and x-ray) are performed within public facilities in the province. Hospital policy concerning access ensures that third
parties are not given priority access.
Medical goods and services that are implanted and
associated with an insured service are provided free of
charge to the patient and are consistent with national
standards of practice. Patients retain the right to financially
upgrade standard medical goods or services. Standards for
medical goods are developed by the hospitals providing
those services in consultation with service providers.
The Medical Care Insurance Act, 1999 provides the
Lieutenant-Governor 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
3.1 Eligibility
There were 530,521 people registered with the program as of
March 31, 2013. 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; dependants of residents if covered by
another province or territory; certified refugees and refugee
claimants and their dependants; foreign workers with
employment authorizations and their dependants who do
not meet the established criteria; tourists, transients, visitors
and their dependants; Canadian Forces personnel; inmates
of federal prisons; and armed forces personnel from other
countries who are stationed in the province. If the status of
these individuals changes, they must meet the criteria for
eligibility as noted above in order to become eligible.
22
3.2 Other Categories of Individuals
Foreign workers, international students, clergy and dependants of North Atlantic Treaty Organization (NATO)
personnel are eligible for benefits. Holders of Minister’s
permits are also eligible, subject to MCP approval.
4.0 PORTABILITY
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 MCP. Immediate coverage is provided to persons
from outside Canada authorized to work in the province
for one year or more.
4.2 Coverage During Temporary Absences in Canada
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.
Canada Health Act — Annual Report 2012–2013
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:
• Before leaving the province for extended periods, a resi-
dent must contact the MCP to obtain an out-of-province
coverage certificate.
• Beneficiaries leaving for vacation purposes may receive
an initial out-of-province coverage certificate of up to
12 months. Upon return, beneficiaries are required to
reside in the province for a minimum four consecutive
months. Thereafter, certificates will only be issued for
up to eight months of coverage.
• Students leaving the province may receive a certificate,
renewable each year, provided they submit proof of fulltime enrolment in a recognized educational institution
located outside the province.
• Persons leaving the province for employment purposes
may receive a certificate for coverage up to 12 months.
Verification of employment may be required.
• Persons must not establish residence in another province,
territory or country while maintaining coverage under
the Newfoundland MCP.
• For out-of-province trips of 30 days or less, an out-of-
province coverage certificate is not required, but will be
issued upon request.
• For 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.
4.3 Coverage During Temporary Absences
Outside Canada
The province provides coverage to residents during
temporary absences outside Canada. Out of country
insured hospital in- and out-patient services are covered
for emergencies, sudden illness, and elective procedures
at established rates. Hospital services are considered
under the Plan when the insured services are provided
by a recognized facility (licensed or approved by the
Canada Health Act — Annual Report 2012–2013
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 hæmodialysis
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.
23
Chapter 3: Newfoundland and Labrador
The Department of Health and Community Services works
closely with educational institutions within the province to
maintain an appropriate supply of health professionals. The
province also works with external organizations for health
professionals not trained in this province. Targeted recruitment incentives are in place to attract health professionals.
Several programs have been established to provide targeted
sign-on bonuses, bursaries, opportunities for upgrading,
and other incentives for a wide variety of health occupations. The many positive results reported throughout
2012–2013, show that our strategic investments are paying
off and that Newfoundland and Labrador (NL) is a leader
in wait time improvements in Canada. The key drivers of
these improvements are the implementation of actions under
the Provincial Emergency Department Wait Time Strategy
as well as the Provincial Hip and Knee Joint Replacement
Wait Time Strategy, which included increased Provincial
Government funding to complete additional joint replacement surgeries.
Newfoundlanders and Labradorians have shorter 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. The report also acknowledged
the province for its steady improvement in these priority
areas while wait times are increasing in other Canadian
jurisdictions.
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 with 88 per
cent of hip fracture repairs performed within the 48-hour
benchmark. The province also performed 81 percent of knee
replacement surgeries within benchmark, which is above
the national average of 75 percent. NL was one of only
two provinces that showed improvement over three years
in meeting the key joint replacement benchmarks.
CIHI also reported that NL outperformed all other provinces
since 2004 by increasing the number of selected surgeries
completed in the benchmark and other areas. Furthermore
provincial results are showing a 20 percent increase in
the proportion of knee replacements completed within the
benchmark in 2012–2013 compared to 2011–2012.
Through the actions of the hip and knee replacement strategy,
expanded hours of physiotherapy services to provide full time
consistent physiotherapy services seven days per week were
implemented in one of the health authorities, which resulted
in reductions in the length of hospital stay of orthopedic
patients, including hip and knee replacements.
Through the actions of the Provincial Emergency Department
Wait Time Strategy, external reviews were carried out at three
Emergency Departments in the province. As a result of this
work, the processes for fast-tracking low acuity patients has
24
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 2012–2013 (January 1 to
March 31), wait time reports demonstrated that, on
average, 90 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 90 days, which
is much sooner than the benchmark of 182 days; 90 percent of first eye cataract procedures were performed within
112 days; 85 percent of residents accessed hip replacement
surgery and 82 percent knee replacement within 182 days;
and 91 percent of hip fracture surgeries were performed
in less than 48 hours.
In keeping with the Department of Health and Community
Service’s strategic plan, wait times for select cancer surgery
and endoscopy services began to be publicly reported on
the website in 2012–2013. As a result, NL was the first
province to post provincial wait times for urgent colonoscopy on a public website.
The provincial government has invested over $140 million over the past eight years to improve wait times. This
includes the establishment of a new Access and Clinical
Efficiency Division within the Department of Health and
Community Services to focus on wait time improvement
strategies. For more information regarding provincial wait
times, visit www.gov.nl.ca/health/wait_times.
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 (RHA)
play a role in this process. A Memorandum of Agreement
was reached with the NLMA in December 2010, which
increases overall physician compensation by approximately
26 percent. The Agreement expired on September 30, 2013.
Physicians are paid via fee-for-service, salary or alternate
payment plan (APP) with an increasing interest in APPs as
a method of remuneration.
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
Canada Health Act — Annual Report 2012–2013
Chapter 3: Newfoundland and Labrador
global budget. Payments are made in accordance with
the Hospital Insurance Agreement Act and the Regional
Health Authorities Act. As part of their accountability to
the government, the health authorities are required to meet
the Department’s annual reporting requirements, which
include audited financial statements and other financial
and statistical information. The global budgeting process
devolves the budget allocation authority, responsibility, and
accountability to all appointed boards in the discharge of
their mandates.
Throughout the fiscal year, the RHAs forwarded additional
funding requests to the Department for any changes in program areas or increased workload volume. These requests
were reviewed and, when approved by the Department,
funded at the end of each fiscal year. Any adjustments to
the annual funding level, such as for additional approved
positions or program changes, were funded based on the
implementation date of such increases and the cash flow
requirements.
Canada Health Act — Annual Report 2012–2013
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
2012–2013, these documents include:
• the 2012–2013 Public Accounts;
• the Estimates 2012–2013; and
• the Budget Speech 2012–2013.
The Public Accounts and Estimates, tabled by the
Government in the House of Assembly, are publicly
available and have been shared with Health Canada
for information purposes.
25
Chapter 3: Newfoundland and Labrador
Registered Persons
1. Number as of March 31st (#).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
514,470
523,433
523,508
527,714
530,521
Insured Hospital Services Within Own Province or Territory
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#).
5. Payments to private for-profit facilities
for insured health services ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
51
51
51
51
51
880,628,613
964,078,687
1,028,697,016
1,088,392,487
1,097,535,388
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
1
1
1
1
1
389,375
432,500
660,625
697,375
845,280
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
1,732
1,595
1,632
1,648
1,844
15,695,411
16,928,930
21,096,749
17,507,684
19,988,002
29,758
25,770
23,156
23,482
27,681
7,680,172
7,325,977
7,214,089
7,216,918
8,827,387
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
26
90
94
97
126
108
368,959
123,890
318,203
224,822
139,270
400
317
445
475
410
204,973
272,567
209,257
91,089
96,116
Canada Health Act — Annual Report 2012–2013
Chapter 3: Newfoundland and Labrador
Insured Physician Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
1,037
1,075
1,096
1,115
1,155
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
not available
not available
not available
not available
not available
199,127,000
211,145,000
216,931,000
218,561,000
236,529,000
14.Number of participating physicians (#).1
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
136,000
147,000
155,000
154,000
114,000
6,161,000
6,991,000
6,665,000
6,627,000
6,762,000
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
2,900
3,100
3,600
3,400
3,400
240,000
157,000
202,000
237,000
231,000
Insured Surgical-Dental Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
25
31
29
25
25
2,995
290
1,093
2,222
2,880
331,000
28,000
158,000
329,000
455,780
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2
1. Excludes inactive physicians.Total salaried and fee-for-service.
2. Number of services and associated dollar figure low in 2009–2010 due to oral surgeon recruitment issues.
Canada Health Act — Annual Report 2012–2013
27
28
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
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;
• establishing mechanisms to improve patient safety
and support quality improvement processes; and
• creating a Crown corporation (Health PEI) to oversee
the delivery of operational healthcare services.
Within this governance structure Health PEI is responsible to:
• provide, or provide for the delivery of, health services;
• operate and manage health facilities;
• manage the financial, human and other resources
necessary to provide health services and operate health
facilities; and
• perform such other duties as the Minister may direct.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and Public Authority
The Hospital Services Insurance Plan, under the authority
of the Minister of Health and Wellness, is the vehicle for
delivering hospital care insurance in Prince Edward Island.
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
Canada Health Act — Annual Report 2012–2013
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. Public Accounts Volume I Consolidated Financial
Statements was published in January 2013. Public Accounts
Volume II Operating Fund Financial Statements, Details of
Revenues and Expenditures, Financial Statements of Agencies
and Crown Corporations was published in February 2013.
The provincial Auditor General, through the Audit Act,
has the discretion to conduct further audit reviews on a
comprehensive or program specific basis.
2.0 COMPREHENSIVENESS
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
29
Chapter 3: Prince Edward Island
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 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 practi­
tioners 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, 2013 was
344. 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, 2013, 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
30
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.
The process to add a physician service to the list of insured
services involves negotiation between the Department,
Health PEI and the Medical Society. The process involves
development of a business plan which, when approved by
the Minister, would be taken to Treasury Board for funding
approval. Insured physician services may also be added or
deleted as part of the negotiation of a new Master Agreement
with physicians (Section 5.2). Cabinet has the final authority
in adding new services.
2.3 Insured Surgical-Dental Services
Dental services are not insured under the Medical Services
Insurance Plan. Only oral maxillofacial surgeons are paid
through the Plan. There are currently two surgeons in
that category. Surgical-dental procedures included as basic
health services in the Tariff of Fees are covered only when
the patient’s medical condition requires that they be done
in hospital or in an office with prior approval, as confirmed
by the attending physician.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Provincial hospital services not covered by the Hospital
Services Insurance Plan include:
• services that persons are eligible for under other
provincial or federal legislation;
• mileage or travel, unless approved by Health PEI;
• telephone consultation except by internists, palliative care
physicians, paediatricians, out-of-province specialists, and
orthopaedic surgeons, provided the patient was not seen
by that physician within 3 days of the telephone consult;
• examinations required in connection with employment,
insurance, education, etc.;
• group examinations, immunizations or inoculations,
unless prior approval is received from Health PEI;
• preparation of records, reports, certificates or communi-
cations, except a certificate of committal to a psychiatric,
drug or alcoholism facility;
Canada Health Act — Annual Report 2012–2013
Chapter 3: Prince Edward Island
•
•
•
•
testimony in court;
travel clinic and expenses;
surgery for cosmetic purposes unless medically required;
dental services other than those procedures included
as basic health services;
• dressings, drugs, vaccines, biologicals and related
materials;
• eyeglasses and special appliances;
• chiropractic, podiatry, optometry, chiropody, osteopathy,
naturopathy, and similar treatments;
• physiotherapy, psychology, and acupuncture except
when provided in hospital;
• reversal of sterilization procedures;
• in vitro fertilization;
• services performed by another person when the
supervising physician is not present or not available;
• services rendered by a physician to members of the
physician’s own household, unless approval is obtained
from Health PEI; and
• any other services that the Department may, upon the
recommendation of the negotiation process between the
Department, Health PEI and the Medical Society, declare
non-insured.
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 2012–2013 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.
Canada Health Act — Annual Report 2012–2013
3.0UNIVERSALITY
3.1 Eligibility
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, 2013, was 148,278.
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.
31
Chapter 3: Prince Edward Island
Temporary workers, refugees and Minister’s Permit holders
are not eligible for hospital and medical insurance benefits.
4.0 PORTABILITY
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.
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.
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.
4.4 Prior Approval Requirement
Prior approval is required from Health PEI before receiving
non-emergency, out-of-province medical or hospital services.
Island residents seeking such required services may apply
for prior approval through a 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 out-of-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 2012–2013
fiscal year include:
• PEI passed the Drug Product Interchangeability and
Pricing Act to control the pricing of generic drugs, and
also expanded the provincial drug formulary to include
additional medications.
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).
• Opened the new Dr. Joseph A. and Eileen McMillan
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.
• Expanded the provincial influenza immunization
For Prince Edward Island residents leaving the country for
work purposes for longer than one year, coverage ends the
day the person leaves.
32
Ambulatory Care Centre. The centre co-locates 22 health
care services, and provides increased square footage
to allow for additional patient-care spaces in order to
increase capacity.
program so that all Islanders age 65 and over receive
free flu shots.
• The PEI Family Medicine Residency Program saw its
second class graduate this year, with four individuals
completing their two year residency. This is a major
milestone for this program as the intent is to better
integrate our medical students so that they will want
to stay and practice in the province.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Prince Edward Island
• The Family Medicine Sponsorship Program was intro-
of PEI’s physicians (excluding locums and visiting specialists)
are compensated under an alternate payment method (nonfee-for-service) as their primary means of remuneration.
As PEI is primarily a rural province where a large segment of
the population resides outside the main service centres, local
access to health services, including acute services delivered
through community hospitals and health centres, is important to small communities. Prince Edward Island continues
to expand health infrastructure necessary to support health
service delivery in rural communities.
5.3 Payments to Hospitals
duced to help enhance the recruitment and retention of
family physicians, and will provide funding for three
medical students per year for a five-year pilot period.
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, 64 percent
Canada Health Act — Annual Report 2012–2013
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.
6.0 RECOGNITION 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 2012–2013 Annual Budget
and in the 2012–2013 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
2012–2013 Annual Report.
33
Chapter 3: Prince Edward Island
Registered Persons
1. Number as of March 31st (#).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
142,305
143,238
146,049
147,942
148,278
Insured Hospital Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
7
7
7
7
7
151,304,500
161,439,600
172,100,500
183,647,900
192,480,600
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
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 ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
2,591
2,692
2,564
2,509
2,553
20,582,454
26,099,326
25,159,408
23,821,199
25,941,946
18,488
17,147
16,763
15,391
19,351
5,290,630
5,385,508
5,286,499
5,136,948
6,566,417
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
34
46
29
43
24
113,901
157,547
70,768
164,610
76,120
122
127
113
165
125
33,919
65,114
44,213
58,796
43,482
Canada Health Act — Annual Report 2012–2013
Chapter 3: Prince Edward Island
Insured Physician Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
256
240
242
232
344
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 (#).
17. Total payments for services provided
by physicians paid through all payment
methods ($).
61,445,780
18.Total payments for services provided by
physicians paid through fee-for-service ($).
41,123,808
2
72,874,951
45,959,450
2
62,670,303
2
49,332,788
60,719,582
2
50,264,859
89,303,392
45,675,441
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
77,830
79,139
80,559
83,086
91,130
5,998,751
6,386,325
6,247,907
6,330,440
7,025,721
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
1,053
786
684
950
1,109
52,601
39,137
31,729
40,600
38,036
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
3
3
2
2
2
424
451
352
377
383
149,794
171,901
137,566
125,392
125,290
1. Prior to 2012–13, the total does not include locums, visiting specialists or other non-complement physicians.
2. Prior to 2012–13, data reported did not capture full comprehensive clinical payments. The reporting mechanism has been corrected such that all relevant
clinical payments are captured and presented in 2012/13.
Canada Health Act — Annual Report 2012–2013
35
36
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
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’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 17.2 percent of the Nova Scotian population
is 65 or over and this figure is expected to reach 25.0 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
Canada Health Act — Annual Report 2012–2013
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 Services Insurance (HSI) and the Medical Services
Insurance (MSI) Plans.
The Department of Health and Wellness administers the HSI
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 (formerly called Atlantic
Blue Cross), 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.
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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 for the physicians to whom it makes
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, as well as the Office
of the Auditor General, has the right, under the terms of the
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
Medavie Blue Cross Incorporated is responsible for
providing over 95 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.
2.0 COMPREHENSIVENESS
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.
In-patient services include:
•
•
•
•
accommodation and meals at the standard ward level;
necessary nursing services;
laboratory, radiological and other diagnostic procedures;
drugs, biologicals and related preparations, when
administered in a hospital;
• routine surgical supplies;
• use of operating room(s), case room(s) and anaesthetic
services;
• use of radiotherapy and physiotherapy services for
in-patients, where available; and
• blood or therapeutic blood fractions.
Out-patient services include:
• laboratory and radiological examinations;
• diagnostic procedures involving the use of
radio-pharmaceuticals;
Canada Health Act — Annual Report 2012–2013
Chapter 3: NOVA SCOTIA
• electroencephalographic examinations;
• use of occupational and physiotherapy facilities,
where available;
•
•
•
•
necessary nursing services;
drugs, biologicals and related preparations;
blood or therapeutic blood fractions;
hospital services in connection with most minor
medical and surgical procedures;
• day-patient diabetic care;
• services provided by the Nova Scotia Hearing and
Speech Clinics, where available;
• ultrasonic diagnostic procedures;
• home parenteral nutrition, where available; and
• haemodialysis and peritoneal dialysis, where available.
In order to add a new hospital service to the list of insured
hospital services, district health authorities are required to
submit a New and/or Expanded Program Proposal to the
Department of Health and Wellness1. This process is carried
out annually by request through the business planning process. A Department-developed process format is forwarded
to the districts for their guidance. A Department of Health
and Wellness working group reviews and prioritizes all
requests received, and based on available funding, a number
of top priorities may be approved by the Minister of Health
and Wellness.
2.2 Insured Physician Services
The legislation covering the provision of insured physician
services in Nova Scotia is the Health Services and Insurance
Act, sections 3(2), 5, 8, 13, 13A, 17(2), 22, 27-31, 35 and
the Medical Services Insurance Regulations.
As of March 31, 2013, 2,507 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,
2013, no physicians had opted out.
Insured services include those that are medically necessary.
Medically necessary may be defined as services provided
by a physician to a patient with the intent to diagnose or
treat physical or mental disease or dysfunction, as well
as those services generally accepted as promoting health
through prevention of disease or dysfunction. Services
that are not medically necessary are not insured. Services
explicitly deemed as non-insured under the Health
Services and Insurance Act or its regulations remain
uninsured regardless of individual judgments regarding the
medical necessity.
Additional services were added to the list of insured physician services in 2012–2013. 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 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 so written 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 2012–2013, 18 dentists were paid
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.
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
1. Emergency or unexpected requirements may be considered at any time throughout the fiscal year.
Canada Health Act — Annual Report 2012–2013
39
Chapter 3: NOVA SCOTIA
specific experts in the field, renders the decision as to whether
or not the new procedure becomes an insured service.
“Other extraction services” (routine extractions) at public
expense 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 provided at public
expense 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 paid at public
expense. 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.
2.4 Uninsured Hospital, Physician and
Surgical-Dental 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;
in-vitro fertilization;
procedures performed as part of clinical research trials;
services such as gastric bypass for morbid obesity, breast
reduction/augmentation and newborn circumcision;2 and
• services not deemed medically necessary that are required
by third parties, such as insurance companies.
• testimony in court;
• services in connection with an electrocardiogram,
electromyogram or electroencephalogram, unless the
physician is a specialist in the appropriate specialty;
•
•
•
•
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.
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 additional cost. Patients are
not denied service based on their inability to pay. The pro­
vince provides alternatives to any of the enhanced goods
and services.
The Department of Health and Wellness carefully reviews
all patient complaints or public concerns that may indicate that the general principles of insured services are not
being followed.
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.
Uninsured physician services include:
• services eligible for coverage under the Workers’
Compensation Act or under any other federal or
provincial legislation;
• mileage, travel or detention time;
• telephone advice (with the exception of a pilot project
currently in place) or telephone renewal of prescriptions;
• examinations required by third parties;
• group immunizations or inoculations unless approved
by the Department;
• preparation of certificates or reports;
3.0 UNIVERSALITY
3.1 Eligibility
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.
2. These services may be insured when approved as special consideration for medical reasons only.
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Canada Health Act — Annual Report 2012–2013
Chapter 3: NOVA SCOTIA
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 pro­
vince 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.
There were no changes to eligibility requirements in
2012–2013.
In 2012–2013, the total number of residents registered
with the health insurance plan was 998,763.
3.2 Other Categories of Individuals
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:
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.”
Convention Refugees and Non-Canadians married to
Canadian Citizens or Permanent Residents (copy of
Marriage Certificate required), who possess any other
document and who have applied within Canada for
Permanent Resident status, will be eligible on the date of
application for Permanent Resident status, provided they
Canada Health Act — Annual Report 2012–2013
possess a letter or documentation from Citizenship and
Immigration Canada stating that they have applied for
Permanent Residence.
Non-Canadians married to Canadian Citizens/Permanent
Residents (copy of Marriage Certificate required), who
possess any other document and who have applied outside Canada for Permanent Resident status, will be eligible
on the date of arrival, provided they possess a letter or
documentation from Citizenship and Immigration Canada
stating that they have applied for Permanent Residence.
In 2012–2013, there were 34,248 Permanent Residents
registered with the health care insurance plan.
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, except 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 dependents.
In 2012–2013, there were 3,277 individuals with
Employment Authorizations covered under the health
care insurance plan.
Study Permits: Persons moving to Nova Scotia from
another country and who possess a Study Permit will be
eligible for MSI on the first day of the thirteenth month
following the month of their arrival, provided they have not
been absent from Nova Scotia for more than 31 consecutive
days, except in the course of their studies. MSI coverage is
extended for a maximum of 12 months at a time and only
for services received within Nova Scotia. Each year, a copy
of their renewed immigration document must be presented
and a declaration signed. Dependants of such persons, who
are legally entitled to remain in Canada, will be granted
coverage on the same basis once the student has gained
entitlement.
In 2012–2013, there were 1,384 individuals with Student
Authorizations covered under the health care insurance plan.
Refugees: Refugees are eligible for MSI if they possess either
a work permit or study permit.
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Chapter 3: NOVA SCOTIA
4.0 PORTABILITY
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.
4.2 Coverage During Temporary Absences in Canada
The Interprovincial Agreement on Eligibility and Portability
is followed in all matters pertaining to the portability of
insured services.
Generally, the Nova Scotia MSI Plan provides coverage for
residents of Nova Scotia who move to other provinces or
territories for a period of three months, per the Eligibility
and Portability Agreement. Students and their dependants,
who are temporarily absent from Nova Scotia and in fulltime 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 full-time students. 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 terri­
tory. Services provided to Nova Scotia residents in other
provinces or territories are covered by reciprocal agreements.
Nova Scotia participates in the Hospital Reciprocal Billing
Agreement and the Medical Reciprocal Billing Agreement.
Québec is the only province that does not participate in the
Medical Reciprocal Billing Agreement. Nova Scotia pays for
services provided by Québec physicians to Nova Scotia residents at Québec rates if the services are insured in Nova Scotia.
The majority of such claims are received directly from Québec
physicians. In-patient hospital services are paid through the
interprovincial reciprocal billing arrangement at the standard
ward rate of the hospital providing the service. Nova Scotia
pays the host province rates for insured services in all reciprocal billing situations. The total amount paid by the plan in
2012–2013 for in-patient and out-patient hospital services
received in other provinces and territories was $32,126,899.
There were no changes made in Nova Scotia in 2012–2013
regarding in-Canada portability.
4.3 Coverage During Temporary Absences
Outside Canada
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
42
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 non-emergency
nature must have prior approval before they will be
covered by MSI.
Students and their dependants who are temporarily absent
from Nova Scotia and in full-time attendance at an edu­
cational 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.
Emergency out-of-country services are 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.
There were no changes made in Nova Scotia in 2012–2013
regarding out-of-Canada portability. The total amount spent
in 2012–2013 for insured in-patient services provided outside of Canada was $1,104,701. Nova Scotia does not cover
out-patient services out-of-country.
4.4 Prior Approval Requirement
Prior approval must be obtained for elective services outside
the country. Application for prior approval is made to the
Medical Director of the MSI Plan by a specialist in Nova
Scotia on behalf of an insured resident. The medical consultant reviews the terms and conditions and determines
whether or not the service is available in the province, or
if it can be provided in another province or only out-ofcountry. 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.
Canada Health Act — Annual Report 2012–2013
Chapter 3: NOVA SCOTIA
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.
In 2009, the province hired Dr. John Ross as the first provincial advisor on emergency care. His recommendations form
the basis of the Better Care Sooner plan, released in 2010.
The plan is designed to: provide and enhance access to doctors, nurses and other healthcare professionals; streamline
patient-centred emergency care; provide better care for
seniors, people with mental illness and other patients with
complex needs; promote greater awareness of emergency telephone number (911) and the HealthLink 811 and; to fund
for performance and quality of care. The plan has identified
32 action items to be implemented from 2011 to 2014.
As part of the plan, seven new Collaborative Emergency
Centers (CECs) have been opened 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 reduced by 92 percent 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 Department also worked with Capital District Health
Authority to expand hours of operation at their Cobequid
Community Health Centre and expand access to the Centre’s
medical/surgical clinic. To better address the needs of individuals requiring dialysis services, the Department has provided
funding to increase support for home hemodialysis and has
invested in the reorganization of satellite dialysis services so
that more complex patients can access hemodialysis closer to
home. The Department also established an enhanced provincial digital mammography service that will enable women
in Nova Scotia to have access to the most current breast
screening technology leading to improved quality care.
Access to Insured Physician Services
Innovative funding solutions such as block funding and
personal services contracts have enhanced 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 has supported an increase in distributed medical
education, 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.
Canada Health Act — Annual Report 2012–2013
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 payments, on-call funding,
specific fee adjustments, dispute resolution processes, and
other process or consultation issues.
Fee-for-service is still the most prevalent method of pay­
ment 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 2012–2013,
approximately 23 per cent of physicians were remunerated
exclusively through alternative funding. Approximately 63 per
cent 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; and QEII 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,
neo­natology, 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
remuneration is not appropriate. Some examples of these
programs would be emergency department funding,
institutional psychiatry funding, and sessional funding.
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Chapter 3: NOVA SCOTIA
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 feefor-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
define the terms for payments by the Minister of Health and
Wellness to hospitals for insured hospital services.
44
In 2012–2013, there were 2928 hospital beds in Nova Scotia
(3.1 beds per 1,000 population). Department of Health and
Wellness direct expenditures for insured hospital services
operating costs were increased to $1,619,915,286.
6.0 RECOGNITION GIVEN TO
FEDERAL TRANSFERS
In Nova Scotia, the Health Services and Insurance Act
acknowledges the federal contribution regarding the cost
of insured hospital services and insured health services provided to provincial residents. The residents of Nova Scotia
are aware of ongoing federal contributions to Nova Scotia
health care through the Canada Health Transfer (CHT)
as well as other federal funds through press releases and
media coverage.
The Government of Nova Scotia also recognized the federal
contribution under the CHT in various published documents,
including the following documents:
• Public Accounts 2012–2013 released July 31, 2013; and
• Budget Estimates and Supplementary Detail 2011–2012
released July 31, 2013.
Canada Health Act — Annual Report 2012–2013
Chapter 3: NOVA SCOTIA
Registered Persons
1. Number as of March 31st (#).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
975,206
981,922
988,585
994,018
998,763
Insured Hospital Services Within Own Province or Territory
Public Facilities
2. Number (#).
3. Payments for insured health services ($). 3
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#).5
5. Payments to private for-profit facilities
for insured health services ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
35
35
35
35
35
1,406,145,241
1,531,561,311
1,560,236,537
1,593,552,159
1,619,915,286
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
4
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
2,310
2,089
1,946
2,402
2,259
15,924,363
16,289,798
13,614,172
19,417,809
19,854,352
42,089
39,443
38,261
36,125
39,611
11,558,634
11,180,204
10,978,035
12,375,773
12,272,547
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
not available
not available
not available
not available
not available
1,190,016
1,286,181
788,368
2,176,921
1,104,701
12.Total number of claims, out-patient (#).
not applicable
not applicable
not applicable
not applicable
not applicable
13.Total payments, out-patient ($).
not applicable
not applicable
not applicable
not applicable
not applicable
11. Total payments, in-patient ($).
3. This reflects payments made to the public facilities noted under for indicator 2 above.
4. 2009–2010 includes payments to the DHAs for Care Coordination as program was integrated with the DHAs in the fiscal year.
5. Scotia Surgery is not considered private, it is classified as a hospital (funded by the Department of Health).
Canada Health Act — Annual Report 2012–2013
45
Chapter 3: NOVA SCOTIA
Insured Physician Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
2,343
2,401
2,434
2,473
2,507
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
17. Total payments for services provided
by physicians paid through all payment
methods ($).
598,546,450
637,434,810
661,968,168
681,963,292
694,184,053
18.Total payments for services provided by
physicians paid through fee-for-service ($).
266,174,648
301,217,024
301,629,014
309,391,089
310,301,903
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of non-participating physicians (#).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
215,490
197,580
195,538
211,030
208,505
7,671,840
7,362,277
7,426,414
8,297,188
8,512,631
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
3,051
3,418
3,092
3,295
2,096
161,555
200,452
169,312
185,142
110,695
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).6
25.Total payments ($).7
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
29
55
26
28
18
6,254
6,536
6,913
7,228
7,007
1,374,645
1,380,344
1,459,608
1,338,592
1,397,223
6.
Total services includes block funded dentists.
7. Total payments does not include block funded dentists.
46
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
New Brunswick
Introduction
1.2 Reporting Relationship
New Brunswick continues its commitment to the five
fundamental principles of the Canada Health Act (CHA),
a commitment evident both in the day to day functioning
of the various elements of the New Brunswick health
system, and in new initiatives announced or implemented
in 2012–2013.
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.
Health expenditure accounts for approximately 40 percent
of the overall budget in New Brunswick and is predicted
to rise. To assist in determining and managing the strategic
change required, in April 2012 a new Office of Health
System Renewal was established to provide focused leadership to quicken efforts towards re-building a healthcare
system that would be sustainable for the generations
to come.
For information about 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.
Canada Health Act — Annual Report 2012–2013
The Regional Health Authorities Act establishes the regional
health authorities (RHAs) and sets forth the powers, duties
and responsibilities of same. The Minister is responsible
for the administration of the Act, provides direction to
each RHA, and may delegate additional powers, duties
or functions to the RHAs.
1.3 Audit of Accounts
Four groups have a mandate to audit the Medical
Services Plan.
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 Department. The Auditor
General also conducts management reviews on programs as he or she sees fit.
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.
3) The Department’s Internal Audit Unit was established
to independently review and evaluate departmental
activities as a service to all levels of management.
4) Medicare has a Monitoring and Compliance team,
which is tasked with managing compliance to the
Medical Payment Services Act and Regulations, as
well as the Negotiated Fee Schedule.
47
Chapter 3: NEW BRUNSWICK
2.0 COMPREHENSIVENESS
The services entitled under Medicare include:
2.1 Insured Hospital Services
a) the medical portion of all medically required services
rendered by medical practitioners;
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 in-patient and out-patient
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.
b) certain surgical-dental procedures when performed by
a physician or a dental surgeon in a hospital facility.
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.
Three new service codes were added during this
reporting period.
1. Botox injections — other than the eye (face — unilateral)
2.2 Insured Physician Services
The Medical Services Payment Act and corresponding
regulations provide for insured physician services. As of
March 31, 2013 there were 1,640 participating physicians
in New Brunswick. No physicians rendering health care services have elected to opt out of the New Brunswick Medical
Services Plan. When a physician opts out of Medicare, they
must complete the specified Medicare claim form and indicate the amount charged to the patient. The beneficiary then
seeks reimbursement by certifying on the claim form that the
services have been received and forwarding the claim form
to Medicare. The charges must not exceed the Medicare
tariff. If the charges are in excess of the Medicare tariff, the
practitioner must inform the beneficiary before rendering
the service that:
• they have opted out and charge fees above the
Medicare tariff;
• in accepting services under these conditions, the
patient waives all rights to Medicare reimbursement;
• the patient is entitled to seek services from another
practitioner who participates in the Medical Services
Plan; and
• the physician must obtain a signed waiver from the
patient on the specified form and forward the form
to Medicare.
48
2. Botox injections — other than the eye (other areas —
unilateral)
3. Upper gastrointestinal botox injection for achalasia
via endoscopy
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. OMS may
also see patients for consultation in their office.
As of March 31, 2013, 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 data for the number of non-enrolled
dental practitioners in New Brunswick.
Canada Health Act — Annual Report 2012–2013
Chapter 3: NEW BRUNSWICK
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital services include: patent medicines; takehome drugs; third-party requests for diagnostic services; visits
to administer drugs; vaccines; sera or biological products;
televisions and telephones; preferred accommodation at
the patient’s request; and hospital services directly related
to services listed under Schedule 2 of the Regulation under
the Medical Services Payment Act. Services are not insured
if provided to those entitled under other statutes.
The services listed in Schedule 2 of New Brunswick
Regulation 84-20 under the Medical Services Payment
Act are specifically excluded from the range of entitled
medical services under Medicare. They are as follows:
• elective plastic surgery or other services for cosmetic
• testimony in a court or before any other tribunal;
• immunization, examinations or certificates for purpose
of travel, employment, emigration, insurance or at the
request of any third party;
• services provided by medical practitioners or oral
and maxillofacial surgeons to members of their
immediate family;
• psychoanalysis;
• electrocardiogram (E.C.G.) where not performed by
a specialist in internal medicine or paediatrics;
• laboratory procedures not included as part of an
examination or consultation fee;
• refractions;
• services provided within the province by medical
practitioners, oral and maxillofacial surgeons or dental
practitioners for which the fee exceeds the amount
payable under regulation;
purposes;
•
•
•
•
correction of inverted nipple;
breast augmentation;
otoplasty for persons over the age of eighteen;
removal of minor skin lesions, except where the
lesions are, or are suspected to be, pre-cancerous;
• abortion, unless the abortion is performed 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;
• surgical 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;
• medicines, drugs, materials, surgical supplies or
prosthetic devices;
• vaccines, serum, drugs and biological products
listed in sections 106 and 108 of New Brunswick
Regulation 88-200 under the Health Act;
• advice or prescription renewal by telephone which is
not specifically provided for in the Schedule of Fees;
• examination of medical records or certificates at the
request of a third party, or other services required by
hospital regulations or medical by-laws;
• dental services provided by a medical practitioner or
an oral and maxillofacial surgeon;
• services that are generally accepted within New
Brunswick as experimental or that are provided as
applied research;
• services that are provided in conjunction with, or
in relation to, the services referred to above;
Canada Health Act — Annual Report 2012–2013
• the fitting and supplying of eye glasses or contact lenses;
• trans-sexual surgery;
• radiology services provided in the province by a private
radiology clinic;
• acupuncture;
• complete medical examinations when performed for
the purposes of periodic check-up and not for medically
necessary purposes;
•
•
•
•
•
•
circumcision of a newborn;
reversal of vasectomies;
second and subsequent injections for impotence;
reversal of tubal ligations;
intrauterine insemination;
bariatric surgery unless the person has a body mass index
of 40 or greater or of 35 or greater but less than 40, as
well as obesity-related comorbid conditions;
• venipuncture for purposes of taking blood when per-
formed 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.
Intraocular lenses are now provided by the hospitals.
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
49
Chapter 3: NEW BRUNSWICK
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 2012–2013, no services were removed from the insured
service list.
3.0UNIVERSALITY
3.1 Eligibility
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 to provide proof of Canadian citizenship, Native status
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, 2013, there were 748,570 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 residence in New Brunswick.
b) Immigrants or Canadian residents moving or returning
to New Brunswick are entitled to first day coverage,
provided they are deemed to have established permanent
residence in the province. Proper documentation is
required (Immigration and Citizenship documentation)
and decisions on coverage/residency are reviewed on a
case-by-case basis.
50
Residents who were not eligible for Medicare coverage
during this reporting period included:
• regular members of the Canadian Armed Forces;
• members of the Royal Canadian Mounted Police;
* Note that, on June 29, 2012, as a result of the federal Jobs, Growth and Long-term Prosperity Act,
the Canada Health Act was amended to allow
members of the RCMP to be eligible for coverage
under provincial and territorial health plans. At the
time this report was compiled, federal, provincial
and territorial governments were in consultation
on the changes in provincial and territorial health
legislation that would be required for members of
the RCMP to be considered insured persons under
provincial and territorial health insurance plans.
• inmates at federal institutions;
• temporary residents;
• a family member who moves from another province to
New Brunswick before other family members move;
• persons who have entered New Brunswick from another
province to further their education and who are eligible
to receive coverage under the medical services plan of
that province; and
• non-Canadians who are issued certain types of Canadian
authorization permits (e.g., a Student Authorization).
Persons who are discharged or released from the Canadian
Armed Forces, or a federal penitentiary, provided they are
residing in New Brunswick when discharged or released,
become eligible for coverage on the date of their discharge or
release. An application must be completed, and the official
date of release and proof of citizenship must be provided
for Canadian Armed Forces personnel.
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, or
living in a common-law relationship with an eligible New
Brunswick resident and still possess a valid immigration
permit. At the time of renewal, they are required to provide
an updated immigration document.
4.0 PORTABILITY
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 residence has been established. The three month
Canada Health Act — Annual Report 2012–2013
Chapter 3: NEW BRUNSWICK
waiting period is legislated under New Brunswick’s Medical
Services Payment Act. Refer to section 3.1 for exceptions.
4.3 Coverage During Temporary Absences
Outside Canada
4.2 Coverage During Temporary Absences in 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).
The legislation that defines portability of health insurance
during temporary absences in Canada is the Medical Services
Payment Act, Regulation 84-20, sub-sections 3(4) and 3(5).
Medicare coverage coverage may be extended upon
request in the case of temporary absences to:
• students in full-time attendance at an educational
institution outside New Brunswick;
• residents temporarily working in another jurisdiction;
and
• residents whose employment requires them to travel
outside the province.
Students
Those in full-time attendance at a university or other approved
educational institution, who leave the province to further their
education in another province, will be granted coverage for a
twelve month period that is renewable, provided the following
terms are met:
• proof of enrolment is provided;
• Medicare is contacted once every twelve months;
• permanent residence 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 twelve months provided
the following terms are met:
• permanent residence 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.
Canada Health Act — Annual Report 2012–2013
Eligibility for “temporarily absent” New Brunswick residents
is determined in accordance with the Medical Services Payment
Act and regulations and the Interprovincial Agreement on
Eligibility and Portability.
Residents temporarily employed outside Canada are
granted coverage for up to twelve months (regardless if
it is known beforehand that they will be absent beyond
the twelve month period), provided they do not establish
residence outside Canada.
Any absence over one hundred and eighty-two days,
whether it is for work purposes or vacation, would require
the Director’s approval. This approval can only be up to
twelve months in duration and will only be granted once
every three years. Families of workers temporarily employed
outside Canada will continue to be covered, provided they
reside in New Brunswick.
New Brunswick residents who exceed the twelve month
extension have to reapply for New Brunswick Medicare
upon their return to the province, and may be eligible for
1st day coverage, reviewed on a case by case basis. However,
a “grace period” of up to fourteen days may be extended to
those residents who have been “temporarily absent” slightly
beyond the twelve month 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, truck
drivers, etc.). Certain guidelines must be met to receive
Mobile Worker designation. They are as follows:
• an application is to be submitted in writing;
• documentation is required as proof of Mobile Worker status
(e.g., letter from employer 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
51
Chapter 3: NEW BRUNSWICK
• 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.
Contract Workers
Any New Brunswick resident accepting a contract outof-country must supply the following information and
documentation:
• a letter of request from the New Brunswick resident with
their signature, detailing their absence, including 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 twelve month period that is
renewable, provided they comply with the following:
• proof of enrolment be provided;
• contact Medicare once every twelve months to
• 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.
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 the Canadian Medical Network 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 of Health.
retain eligibility;
• permanent residence is not established outside
5.0ACCESSIBILITY
• health coverage is not received elsewhere.
5.1 Access to Insured Health Services
4.4 Prior Approval Requirement
New Brunswick’s health care system delivers 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. Therefore, all residents of New Brunswick have equal
access to these services.
New Brunswick; and
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, those who receive such services will assume
responsibility for 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/equivalent or alternate service must
not be available in Canada;
52
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.
Canada Health Act — Annual Report 2012–2013
Chapter 3: NEW BRUNSWICK
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.
Funding for FacilicorpNB, a shared services agency that
manages the information technology, materials management
and clinical engineering components of the hospital facilities
in New Brunswick, is also based on the Current Service
Level approach.
5.3 Payments to Hospitals
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.
The legislative authorities governing payments to hospital
facilities in New Brunswick are the Hospital Act, which
governs the administration of hospitals, and the Hospital
Services Act, which governs the financing of hospitals. The
Regional Health Authorities Act provides for the delivery
and administration of health services in defined geographic
areas within the province.
The Department mainly distributes available funding
to New Brunswick’s regional health authorities (RHAs)
through a Current Service Level approach. The funding
base of the RHA from the previous year is the starting point,
to which approved salary increases and a global inflator
for non-wage items are added. This applies to all clinical
services provided by hospital facilities, as well as support
services (e.g., administration, laundry, food services, etc.).
Funding for the Extra-Mural Program (home care) is also
part of the RHA base.
Canada Health Act — Annual Report 2012–2013
6.0 RECOGNITION 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.
53
Chapter 3: NEW BRUNSWICK
Registered Persons
1. Number as of March 31st (#).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
742,974
744,048
748,352
748,406
748,570
Insured Hospital Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
53
56
57
56
59
1,449,216,237
1,590,399,994
1,616,340,008
1,721,356,342
1,736,939,230
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
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 ($).
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
3,919
4,036
4,537
3,925
4,820
37,772,992
37,343,696
44,337,432
38,410,486
48,373,187
46,824
49,005
44,444
32,310
60,927
12,858,195
14,912,717
14,186,848
11,455,683
21,213,988
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
196
251
245
242
274
753,104
556,678
607,147
808,783
202,669
1,430
1,575
1,805
1,285
1,080
561,855
883,980
798,355
857,130
286,912
1. There are no private for-profit facilities providing insured health services in New Brunswick.
54
Canada Health Act — Annual Report 2012–2013
Chapter 3: NEW BRUNSWICK
Insured Physician Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
1,500
1,571
1,588
1,618
1,640
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($). 3
441,197,899
505,899,089
538,111,685
543,148,047
581,432,080
18.Total payments for services provided by
physicians paid through fee-for-service ($).
260,939,796
273,030,951
279,663,511
306,092,105
307,211,084
14.Number of participating physicians (#).2
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
197,023
266,918
209,868
182,746
210,727
11,607,119
16,206,261
11,965,539
13,221,951
15,089,061
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
4,175
5,885
4,610
5,072
6,425
341,618
440,957
568,937
635,020
397,912
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#). 4
24.Number of services provided (#).
25.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
26
26
14
23
20
3,323
3,363
2,722
2,859
4,949
571,175
385,796
367,905
712,367
663,654
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 Bruswick’s Medical Services Plan during each fiscal year.
In 2012–2013, of the 100+ dentists and OMSs registered, these 20 billed the Medical Services Plan.
Canada Health Act — Annual Report 2012–2013
55
56
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
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.
2.0 COMPREHENSIVENESS
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.
Canada Health Act — Annual Report 2012–2013
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 and
last-resort financial assistance recipients, and acrylic dental
prostheses for last-resort financial assistance recipients;
prostheses, orthopaedic appliances, locomotion and postural aids, and other equipment that helps with a physical
disability; external breast prostheses; ocular prostheses;
hearing aids, assistive listening devices and visual aids for
people with a visual or auditory disability; and permanent
ostomy appliances.
With regard to drug insurance, since January 1, 1997, the
Régie has covered, in addition to its regular clientele (lastresort financial assistance recipients and persons 65 years
of age or older), Quebec residents who would not otherwise
have access to a private drug insurance plan. In 2012–2013,
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 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.
57
Chapter 3: Quebec
2.3 Insured Surgical-Dental Services
Services insured under this plan include oral surgery
performed by dental surgeons and specialists in oral and
maxillo-facial surgery, in a prescribed hospital centre or
university institution.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital services include: plastic surgery; 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 institution
58
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
and RCMP 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.
Canada Health Act — Annual Report 2012–2013
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
of 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 North Bay.
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
Canada Health Act — Annual Report 2012–2013
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 C$100 per day if the patient was hospitalized (including in the case of day surgery) or to
a maximum of C$50 per day for outpatient services.
However, haemodialysis treatments are covered to a
maximum of C$220 per treatment, including medications, whether the patient is hospitalized or not. In these
cases, the Régie covers the associated professional services at the lowest cost, either the amount actually paid
or what would have been paid by the Régie for the same
services in Quebec. The services must be delivered in a
hospital, or hospital centre, recognized and accredited
by the appropriate authorities. No reimbursements are
made for nursing homes, spas or similar establishments.
Costs for insured services provided by physicians, dentists,
oral 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 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.
59
Chapter 3: Quebec
4.4 Prior Approval Requirement
Insured persons requiring medical services in hospitals
elsewhere in Canada or abroad that are not available in
Quebec are reimbursed 100 percent if prior consent has
been given for medical and hospital services that meet certain conditions. Consent is not given by the Plan’s officials
if the medical service in question is available in Quebec.
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, 2013, Quebec had 112 institutions operating as hospital centres for a clientele suffering from acute
illnesses. On that date, 20,388 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, 2011, to March 31, 2012,
Quebec hospital institutions had 739,947 admissions for
short stays (including newborns) and 379,901 registrations for day surgeries. These hospitalizations accounted
for 5,189,872 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
well-being of the people in that territory.
60
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 to provide services ranging from assessment
of health status to case management, monitoring, diagnosis
and treatment of acute and chronic problems, and disease
prevention. 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,
2013, there were 253 accredited FMGs and 51 networkclinics in Quebec. Thirty-nine of the network-clinics are
also FMGs.
5.2 Physician Compensation
Physicians are remunerated in accordance with the negotiated
fee schedule. The Minister may enter into an agreement with
the organizations representing any class of health professional.
This agreement may prescribe a different rate of compensation
for medical services in a territory where the number of professionals is considered insufficient.
While the majority of physicians practise within the provincial plan, Quebec allows two other options: professionals
who 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 2012–2013
the Régie paid an estimated $5798 million to doctors in the
province, while the amount for medical services outside the
province reached an estimated $13.1 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 2012–2013 to institutions operating
as hospital centres for insured health services provided to
residents of Quebec totalled nearly $10.8 billion. Payments
to hospital centres outside Quebec for hospital services
totalled approximately $203.40 million.
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
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, Ontario’s
health care system was supported by over $47.6 billion
(including capital) in spending for 2012–2013.
The Ministry 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 Ministry 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 LongTerm Care (MOHLTC). OHIP was established in 1972
and is continued under the Health Insurance Act, Revised
Statutes of Ontario, 1990, c. H-6, to provide insurance in
respect of the cost of insured services provided to Ontario
residents (as defined in the Health Insurance Act) in hospitals and health facilities, and by physicians and other health
care practitioners.
Local Health Integration Networks (LHINs) were established
under the Local Health System Integration Act, 2006 (LHSIA)
to 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. As of April 1, 2007, the LHINs have had responsibility
for funding, planning and integrating health care services at
Canada Health Act — Annual Report 2012–2013
the local level. These include 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 principles 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.
The LHSIA requires each LHIN to prepare an annual report
on its affairs and operations for the previous fiscal year. The
Agency Establishment and Accountability Directive, more
specifically, requires that every operational service agency
(including LHINs) prepare an annual report. The Minister
is required to table the reports in the Legislative Assembly
of Ontario.
The Ministry 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. LHSIA provides the LHINs with the
authority to fund defined health service providers and to
enter into service accountability agreements with health
service providers.
1.3 Audit of Accounts
Every year the Auditor General of Ontario reports on the
results of his examination of government resources and
administration. The Auditor General’s report is tabled by
the Speaker of the Legislative Assembly, usually in the fall,
at which time it becomes available to the public. Audit
reports on select areas of the Ministry 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 12, 2012.
The Ministry’s accounts and transactions are published annually in the Public Accounts of Ontario. The 2012–2013 Public
Accounts of Ontario was released on September 10, 2013.
61
Chapter 3: Ontario
2.0 COMPREHENSIVENESS
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, anaesthetic
facilities; surgical supplies; necessary nursing service; supply
of drugs, biologicals, and related preparations (subject to
some exceptions); certain other specified services, for example,
the provision of equipment, radiotherapy, occupational
medication to haemophiliac patients for use at home; and
certain specified home-administered drugs.
surgical and diagnostic services, including primary health
care services. Services are provided in a variety of settings,
including: private physician offices, community health centres, hospitals, mental health facilities, licensed independent
health facilities, and long-term care homes.
In general terms, insured physician services include: diagnosis
and treatment of medical disabilities and conditions; medical
examinations and tests; surgical procedures; maternity care;
anaesthesia; radiology and laboratory services in approved
facilities; and immunizations, injections and tests.
The Schedule of Benefits 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 2012–2013, 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 (this was permitted on a “grandparented” basis
following proclamation of the Commitment to the Future
of Medicare Act in 2004).
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.
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.
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. The process to
change regulations is managed by Cabinet and includes a
public consultation process.
There were approximately 27, 242 physicians who
submitted claims to OHIP in 2012–2013. This figure
includes physicians submitting both fee-for-service claims
and physicians included in an alternative payment plan
who submitted tracking or shadow-billed claims.
No regulation changes to add hospital services were
completed in fiscal year 2012–2013.
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 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. Physicians provide medical,
62
2.3 Insured Surgical-Dental Services
In accordance with the Canada Health Act, certain
surgical-dental services are prescribed as insured services
under section 16 of Regulation 552 in the Health Insurance
Act and the Schedule of Benefits — Dental Services. The
Health Insurance Act authorizes OHIP to cover a limited
number of procedures when, generally speaking, 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.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Ontario
Generally, insured dental services include: oral and
maxillo-facial surgery that normally would be required
to be performed in a hospital; root resection and apical
curettage procedures when performed in association with
other insured dental procedures; and dental extractions
when performed in a hospital for the safety of high risk
patients and if prior approval is obtained from the Ministry
of Health and Long-Term Care.
With respect to insured surgical-dental services, MOHLTC
negotiates changes to the Schedule of Benefits — Dental
Services with the Ontario Dental Association. In 2002–2003,
MOHLTC and the Ontario Dental Association agreed on
a multi-year funding agreement for dental services, which
became effective on April 1, 2002. Insured surgical-dental
services were provided by 273 dental surgeons in Ontario in
2012–2013.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital services include but are not limited to:
private or semi-private accommodation unless prescribed
by a physician, oral-maxillofacial surgeon or midwife;
telephones and televisions; charges for certain private-duty
nursing; and provision of medications for patients to take
home from hospital, with prescribed exceptions.
Section 24 of Regulation 552 details some specified physician and supporting services that are not insured services.
Uninsured physician services include: services that are not
medically necessary; 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 at the 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 long-distance 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. This includes dental implants, prosthetic
restorations (fixed bridges and dentures) as replacement of
teeth, orthodontic treatment, fillings and crowns.
Canada Health Act — Annual Report 2012–2013
3.0 UNIVERSALITY
3.1 Eligibility
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. With a few exceptions
which are noted in regulation, to be considered a resident
of Ontario for the purpose of obtaining Ontario health
insurance coverage, Regulation 552 under the Health
Insurance Act requires that a person must:
• hold Canadian citizenship or an immigration status
as prescribed in Regulation 552 under the Health
Insurance Act;
• make his or her primary place of residence in Ontario;
• subject to some limited exceptions, be physically
present in Ontario for at least 153 days in any
12-month period; and
• for most new and returning residents, be physically
present in Ontario for 153 of the first 183 days
following the date residence is established in Ontario
(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, including those
who do not hold an immigration status or other status that
is set out in Regulation 552, such as tourists, transients and
visitors to the province. 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 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 Ontario health
insurance coverage but whose status and/or residency situation has changed (e.g., change in immigration status), may
be eligible upon application and subject to the requirements
of Regulation 552.
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Chapter 3: Ontario
Approximately 13.3 million Ontario residents were registered with OHIP and held valid and active health cards as
of March 31, 2013.
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/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
or Permanent Resident/Landed Immigrant applicants.
The individuals listed below who are residents in Ontario
may be eligible for Ontario health insurance coverage in
accordance with Regulation 552 of the Health Insurance
Act. Individuals are required to apply in person to register
for Ontario health insurance coverage. Registration for
OHIP is provided by 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 Ontario health
insurance coverage.
Holders of Temporary Resident Permits: A Temporary
Resident Permit is issued to an individual by CIC when
there are compelling reasons to admit an individual into
Canada who would otherwise be inadmissible under the
federal Immigration and Refugee Protection Act. Each
Temporary Resident Permit has a case type or numerical
designation on the permit that indicates the circumstances
allowing the individual entry into Canada. Individuals who
hold a permit with a case type of 86, 87, 88, 89, 90, 91, 92,
93, 94, 95 or 80 (if for adoption) are eligible for 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 Ontario health insurance 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
64
six months, as long as the member is legally entitled to
stay in Canada.
A foreign worker is eligible for Ontario health insurance
coverage if the individual has been issued a Work Permit or
other document by CIC that permits the person to work in
Canada if the person also has a formal agreement in place
to work full-time for an employer in Ontario. The work
permit/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
Ontario health insurance 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 Ontario health insurance 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 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
Ontario health insurance coverage.
3.3 Premiums
No premiums are required to obtain Ontario health
insurance 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
Canada Health Act — Annual Report 2012–2013
Chapter 3: Ontario
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 the Regulation, or sub section 11(2.1) of the Health
Insurance Act.
Assessment of whether or not an individual is subject to
the interprovincial waiting period occurs at the time of their
application for Ontario health insurance coverage. Examples
of those who are exempt from the three-month 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
Canada Health Act — Annual Report 2012–2013
12 month maximum, he or she should apply for coverage
in the province or territory where that person has been
working or seeking work.
Insured students who are temporarily absent from Ontario,
but remain within Canada, may be eligible for continuous
health insurance coverage for the duration of their full-time
studies, provided they do not establish permanent residency
elsewhere during this period. To ensure that they maintain
continuous OHIP eligibility, a student should provide the
Ministry of Health and Long-Term Care (MOHLTC) with
documentation or information from their educational institution confirming registration as a full-time student. Insured
family members (spouses and dependants) of students who
are studying in another province or territory are also eligible
for continuous OHIP eligibility while accompanying students for the duration of their studies.
In accordance with Regulation 552 of the Health Insurance
Act, most insured residents who want to travel, work or
study outside Ontario, but within Canada, and maintain
OHIP coverage, must have resided in Ontario for at least
153 days in the last 12-month period immediately prior to
departure from Ontario.
Ontario participates in Reciprocal Hospital Billing Agreements
with all other provinces and territories for insured in-patient
and out-patient hospital services. 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 also participates in the Physicians’
Reciprocal Billing Agreements with all other provinces and
territories, except Quebec (which has not signed a reciprocal
agreement with any other province or territory), for insured
physician services. Ontario residents who may be required
to pay for physician services received in Quebec can submit
their receipts to MOHLTC for payment as an insured service
at Ontario rates.
4.3 Coverage During Temporary Absences
Outside Canada
Health insurance coverage for insured Ontario residents
during extended absences (longer than 212 days) outside Canada is governed by sections 1.7 through 1.14
of Regulation 552 of the Health Insurance Act.
The Ministry 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 the regulations and MOHLTC policy,
most applicants must also have been residents in Ontario
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Chapter 3: 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
Ontario health insurance 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 28.6 inclusive, and sections 29
and 31 of Regulation 552 of the Health Insurance Act.
Out-of-country emergency hospital costs are reimbursed
at Ontario fixed per diem rates of:
• a maximum $400 (CAD) for in-patient services for
the level of care 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 services
that include renal dialysis.
During 2012–2013, emergency, medically necessary,
out-of-country physician services were reimbursed at the
Ontario rates set out in Regulation 533 under the Health
Insurance Act or the amount billed, whichever was less.
Charges for medically necessary emergency or out-ofcountry in-patient and out-patient services are reimbursed
only when rendered in an eligible hospital or health facility.
Medically necessary out-of-country laboratory services,
when done on an emergency basis by a physician, are
reimbursed in accordance with the formula set out in
section 29(1)(b) of the Regulation or the amount billed,
whichever is less, and when done on an emergency basis
by a laboratory, in accordance with the formula set out
in section 31 of the Regulation.
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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 out-of-country
insured health services.
The prior approval application must establish that the
services or tests are:
• medically necessary;
• the identical or equivalent service is not performed
in Ontario, or the identical or equivalent service is
performed in Ontario but it is necessary that the
insured person travel out of Canada to avoid a delay
that would result in death or medically significant
irreversible tissue damage;
• generally accepted by the medical profession in Ontario
as appropriate for a person in the same circumstances as
the insured person;
• not experimental;
• not performed for research purposes or survey; and
• written prior approval of payment is granted by the
General Manager before any of the health services are
rendered.
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 2012–2013 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.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Ontario
All insured persons are entitled to all insured physician,
surgical-dental and hospital services, as defined in the
Health Insurance Act and regulations.
Access to insured services is protected under Part II of
the Commitment to the Future of Medicare Act (CFMA),
“Health Services Accessibility.” The CFMA prohibits any
person or any entity from charging or accepting payment
or other benefit for an insured service rendered to an insured
person except as permitted in the CFMA. In addition, the
CFMA prohibits physicians, practitioners and hospitals
from refusing to provide an insured service if an insured
person chooses not to pay a “block fee” for an uninsured
service. The CFMA further prohibits any person or entity
from paying, conferring, charging, or accepting a payment or other benefit in exchange for preferred access for
an insured person to an insured service.
The Ministry of Health and Long-Term Care (MOHLTC)
investigates all possible contraventions of Part II of the
CFMA that come to its attention. For situations in which
it is found that a patient has been extra-billed, the Ministry
ensures that the amount is repaid to that patient.
The 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 Ministry. 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;
Primary Health Care: During 2012–2013, 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 under
OHIP 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 2012–2013, MOHLTC continued to administer
various initiatives in order to improve access to health care
services across the province. Ontario has taken 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:
• stabilizing the significant expansion in medical
education since 2003;
• supporting rural and remote clinical education
opportunities for medical students;
• supporting the Northern Ontario School for Medicine;
• supporting training and assessment programs for
International Medical Graduates and other qualified
physicians who do not meet certain requirements for
practice in Ontario; and
• Supporting the HealthForceOntario Marketing and
Recruitment Agency to help recruit and retain health care
professionals in Ontario communities that need them.
There are a number of existing initiatives to improve
access across Ontario, including but not limited to the
HealthForceOntario Northern and Rural Recruitment
and Retention Initiative (NRRR), the Northern Physician
Retention Initiative (NPRI), and the Northern Health
Travel Grant (NHTG) Program.
• HealthForceOntario Northern and Rural Recruitment
and Retention Initiative: The NRRR supports the
recruitment and retention of physicians in rural and
northern communities. The NRRR provides financial
recruitment incentives to physicians who establish a
full time practice in an eligible community. Community
eligibility for the NRRR is based on a Rurality Index
for Ontario score of 40 or more. The five Northern
Ontario Census Urban Referral Centre census metropolitan areas (Thunder Bay, Sudbury, North Bay, Sault
Ste. Marie and Timmins) are also eligible.
critical care services; and
organ and tissue donation and organ transplantation.
Canada Health Act — Annual Report 2012–2013
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Chapter 3: Ontario
• 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.
• Northern Health Travel Grant Program: The NHTG
Program helps defray travel-related costs for residents
of Northern Ontario who must travel long distances
to access OHIP insured services that are not locally
available, within a radius of 100km. The travel grants
are designed to ensure access to medical specialist
services, or procedures performed at designated health
care facilities. The NHTG Program also promotes using
specialist services located in Northern Ontario, which
encourages more specialists to practice and remain in
the north.
5.2 Physician Compensation
Physicians are paid for the services they provide through a
number of mechanisms. Some physician payments are provided through fee-for-service arrangements. Remuneration is
based on the Schedule of Benefits under the Health Insurance
Act. Other physician payment models include Primary Health
Care Models (such as blended capitation models), Alternate
Payment Plans, and new funding arrangements for physicians
in Academic Health Science Centres.
In 2012–2013, 97% of General Practitioners received feefor-service 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,
Family Health Group, Family Health Network (FHN),
Family Health Organization (FHO), Community Health
Centres, Rural and Northern Physician Group Agreement
(RNPGA), Group Health Centre, Blended Salary Model
(BSM), and specialized agreements.
Family Health Teams (FHTs) build upon existing primary
health care physician funded models by providing funding for
inter-disciplinary 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).
68
MOHLTC negotiates many elements of physician compensation with the Ontario Medical Association. The current
Physician Services Agreement expires on March 31, 2014.
It includes provisions that modernize the delivery of health
care, lower wait times through e-consultations, expand access
to family doctors for seniors and patients with higher needs
(including an expansion of house calls), and support the
sustainability of the health care system and the protection
of high quality patient care.
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.
As of April 1, 2012, Ontario began the implementation of
the Health System Funding Reform (HSFR) Strategy for
funding hospitals. HSFR shifts health care funding from
the current 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 will expand on the 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 currently funded, which is still largely
based on historically-derived 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 Health Service
Provider’s (HSP) total funding by the end of a multi-year
implementation period.
• Health-Based Allocation Model (HBAM):
Organizational-level funding: allocated to HSPs
as determined by characteristics of the population
being served. HBAM is both a funding allocation
methodology and a management tool for strategic
decision-making. The primary objective of HBAM
is to enable government to equitably allocate funding
to the 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.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Ontario
• 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 will be
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. The Clinical Expert Advisory Groups are comprised
of cross-sectoral, multi-geographic and multi-disciplinary
membership with representation from patients as well.
The panel members leverage their clinical experience and
knowledge to define the patient populations and recommend
best practices.
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. As implementation evolves,
the acute QBPs will be developed further to address the
transition to post-acute phase. Additionally, QBPs are being
explored for complex individuals receiving community
services.
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.
In introducing the QBPs, there is a strong interest to
monitor and measure how well QBPs help to standardize
care, minimize practice variation and encourage investments
in quality improvement for better outcomes. In addition,
there is recognition that to enable quality improvement,
it is important that health service providers and clinicians
Canada Health Act — Annual Report 2012–2013
know how well they are performing on those QBPs. Thus,
to evaluate the impact of the QBPs against indicators of
quality, an integrated scorecard approach has been developed.
The implementation of HSFR is a critical enabler for health
system transformation; it is aimed to respond to the needs
of patients and populations, be an incentive to improving
quality, efficiency and integration. The HSFR combines
activity-based funding with global funding that along with
the Excellent Care for All Act (ECFAA) creates a system
that promotes access, quality and efficiency, and establishes
payment levers to advance policy and system objectives
while still ensuring overall cost containment. HSFR implementation is a critical structural reform for reducing health
spending growth from current 6%–7% annual increases to
3.1% by 2012–2013.
When they assumed responsibility for their local health
care systems, Local Health Integration Networks (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 third time to cover
2012–2013.
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. These performance indicators
work to measure and improve:
• person experience (e.g., emergency room length of stay);
• balancing the budget in a way that sustains organizational health (e.g., current ratio [consolidated], total
margin [consolidated]);
• system perspective (e.g., percentage alternate level of
care days);
• volumes (i.e., target volumes expected for rehabilitation,
complex continuing care, mental health, total acute care;
Wait Time volumes for MRI, CT, hip and knee replacement surgery, selected cardiac services; and QBP volumes
such as cataract surgery).
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 a risk, there are a number of options
69
Chapter 3: Ontario
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 Interprovincial Hospital Reciprocal Billing Agreements
are a convenient administrative arrangement in which provincial or territorial governments reimburse hospitals in their
jurisdictions for insured services provided to patients from
other provinces or territories.
The Government of Ontario publicly acknowledged the
federal contributions provided through the Canada Health
Transfer in its 2012–2013 publications.
MOHLTC reviews chronic care co-payment regulations
and rates annually, accounting for changes in the Consumer
Price Index and Old Age Security, and determines whether
revisions to the regulations and rates are appropriate.
70
Canada Health Act — Annual Report 2012–2013
Chapter 3: Ontario
Registered Persons
2008–2009
1. Number as of March 31st (#).
12,800,000
2009–2010
1
12,900,000
2010–2011
1
13,100,000
2011–2012
13,212,728
1
2012–2013
1
13,349,791
1
Insured Hospital Services Within Own Province or Territory
2008–2009
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
2009–2010
2011–2012
2012–2013
149
2
149
2
149
2
147
2
146
14,200,000,000
3
14,800,000,000
3
15,527,899,500
3
16,173,889,100
3
16,418,200,000
2008–2009
Private For-Profit Facilities
2010–2011
2009–2010
2010–2011
2011–2012
2
2012–2013
4. Number of private for-profit facilities
providing insured health services (#).
not available
4
not available
4
not available
4
not available
4
not available
5. Payments to private for-profit facilities
for insured health services ($).
not available
4
not available
4
not available
4
not available
4
not available
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
9,457
8,185
8,231
6,365
7,019
65,183,888
64,688,077
68,384,505
46,960,837
58,107,802
161,193
138,594
130,855
116,541
130,058
38,030,901
36,399,952
35,431,819
33,598,383
37,866,652
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
21,869
28,223
28,420
30,348
29,616
136,036,532
91,456,638
52,706,316
42,559,353
43,824,878
12.Total number of claims, out-patient (#).
not available
5
not available
5
not available
5
not available
5
not available
13.Total payments, out-patient ($).
not available
6
not available
6
not available
6
not available
6
not available
1. These estimates represent the number of Valid and Active Health Cards (have current eligibility and resident has incurred a claim in the last 7 years).
2. Number represents all publicly-funded hospitals excluding specialty psychiatric hospitals. Specialty psychiatric hospitals are excluded in order to conform
to CHAAR reporting guide.
3. Amount represents funding for all public hospitals excluding specialty psychiatric hospitals.
4. Data are not collected in a single system in MOHLTC. Further, the MOHLTC is unable to categorize providers/facilities as “for-profit” as MOHLTC does
not have financial statements detailing service providers’ disbursement of revenues from the Ministry.
5. Included in #10.
6. Included in #11.
Canada Health Act — Annual Report 2012–2013
71
Chapter 3: Ontario
Insured Physician Services Within Own Province or Territory
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of non-participating physicians (#).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
24,411
25,166
25,995
26,818
27,242
39
35
34
32
29
0
7
0
7
0
7
0
7
Not available
17. Total payments for services provided
by physicians paid through all payment
methods ($).
9,061,430,909
8
9,727,123,611
8
10,374,311,208
8
11,008,532,900
8
11,228,719,988
18.Total payments for services provided by
physicians paid through fee-for-service ($).
6,528,353,572
6,812,333,798
7,052,261,365
7,508,636,523
7,402,377,170
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
683,377
596,430
723,766
536,447
553,823
26,471,536
26,204,597
25,237,480
25,252,852
26,017,930
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
247,741
216,715
213,717
234,420
214,080
54,780,594
41,652,064
12,455,597
7,922,281
6,537,845
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
291
277
282
262
273
99,212
99,427
96,797
96,735
93,672
13,916,464
14,324,505
13,525,890
13,532,519
12,525,404
7. Ontario has no non-participating physicians, only opted-out physicians who are reported under item #15.
8. 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, and 2011–2012 have been updated to agree with Public Accounts.
— Fiscal Year 2012-2013 is based on Interim (Unpublished) Public Accounts.
72
Canada Health Act — Annual Report 2012–2013
8
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
Manitoba
Introduction
Manitoba Health provides leadership and support to protect,
promote and preserve the health of all Manitobans. Manitoba
Health continues efforts to improve access, service delivery,
capacity, innovation, sustainability and improve the health
status of Manitobans and reduce 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, etc.
Manitoba Health remains committed to the principles of
Medicare and improving the health status of all Manitobans.
In support of these commitments, highlights of activities
initiated in 2012–2013 included:
• Amalgamation of eleven regional health authorities
into five was achieved while maintaining service delivery,
senior management alignment and governance.
• Advanced the Cancer Wait Time Strategy entitled,
Transforming the Cancer Patient Journey in Manitoba,
aiming to reduce time from suspicion of cancer to treatment to less than two months.
• Continued work on the Aging in Place/Long Term
Care Strategy renamed “Advancing Continuing Care
Blueprint” to support individuals to age within
community living environments.
• Increased access for Manitobans to health care teams
and tools within the Family Doctor for Every Manitoban
by 2015 initiative.
• Continued to move forward on the Lean Six Sigma
Strategy, a province-wide 5-year training and mentoring
strategy for system efficiency and quality improvement.
• Continued implementation of Releasing Time to Care,
an empowerment strategy for nurses and their colleagues
to lead changes that make a difference for them and
their patients.
• Engaged in discussions to facilitate physician participation
in RHA joint planning and service delivery.
Canada Health Act — Annual Report 2012–2013
• Conducted public consultation meetings and established
an online survey to hear suggestions for increasing community engagement in health care.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and Public Authority
The Manitoba Health Services Insurance Plan (MHSIP) is
administered by Manitoba Health under the Health Services
Insurance Act, R.S.M. 1987, c. H35.
The MHSIP is administered under this Act for insurance in
respect of the costs of hospital, personal care, and medical
and other health services referred to in acts of the Legislature
or regulations thereunder.
The Minister of Health is responsible for administering
and operating the Plan. 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 2012–2013 fiscal year that affected the
public administration of the Plan.
1.2 Reporting Relationship
Section 6 of the Health Services Insurance Act requires the
Minister to have audited financial statements of the Plan
showing separately the expenditures for hospital services,
medical services and other health services. The Minister is
required to prepare an annual report, which must include
the audited financial statements, and to table the report
before the Legislative Assembly within 15 days of receiving
it, if the Assembly is in session. If the Assembly is not in
session, the report must be tabled within 15 days of the
beginning of the next session.
73
Chapter 3: MANITOBA
1.3 Audit of Accounts
Section 7 of the Health Services Insurance Act requires that
the Office of the Auditor General of Manitoba (or another
auditor designated by the Office of the Auditor General
of Manitoba) audit the accounts of the Plan 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 2012–2013 fiscal year and is contained
in the Manitoba Health Annual Report, 2012–2013. It is
available at www.gov.mb.ca/health/ann/index.html.
2.0 COMPREHENSIVENESS
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, 2013, 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
out-patient hospital services include: accommodation and
meals at the standard ward level; necessary nursing services;
laboratory, radiological and other diagnostic procedures;
drugs, biologics and related preparations; routine medical
and surgical supplies; use of operating room, case room and
anaesthetic facilities; and use of radiotherapy, physiotherapy,
occupational and speech therapy facilities, where available.
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. As of
March 31, 2013, there were 2,354 physicians registered
in Manitoba.
A physician, by giving notice to the Minister in writing,
may elect to collect the fees for medical services rendered to
74
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.
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 2012–2013.
The range of physician services insured by Manitoba Health 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 2012–2013, 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 Manitoba Health 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 Manitoba Health. Manitoba Health
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 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 2012–2013.
Canada Health Act — Annual Report 2012–2013
Chapter 3: MANITOBA
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 Manitoba Health.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
The Excluded Services Regulation (M.R. 46/93) made under
the Health Services Insurance Act sets out those services that
are not insured. These include: examinations and reports for
reasons of employment, insurance, attendance at university
or camp, or performed at the request of third parties; group
immunization or other group services except where authorized by Manitoba Health; 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 Manitoba Health 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 Manitoba Health
to monitor usage and service concerns.
To de-insure services covered by Manitoba Health, 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 Manitoba Health in 2012–2013.
3.0UNIVERSALITY
3.1 Eligibility
The Health Services Insurance Act defines the eligibility of
Manitoba residents for coverage under the provincial health
care insurance plan.
Section 2(1) of the Act states that a resident is a person
who is legally entitled to be in Canada, makes his or her
home in Manitoba, is physically present in Manitoba for
Canada Health Act — Annual Report 2012–2013
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 fulltime 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).
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
was amended in 2013 to remove any 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 under legislation of
any other jurisdiction (Excluded Services Regulations subsection 2(2)). These residents become eligible for Manitoba
Health 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 (Residency and Registration Regulation
(M.R. 54/93, subsection 2(3)).
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 Manitoba and have been eligible for benefits
under the Manitoba Health Plan effective April 1, 2013.
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Chapter 3: MANITOBA
The process of issuing health insurance cards requires that
individuals inform and provide documentation to Manitoba
Health 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, Manitoba Health 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 Manitoba Health to pay
for all medical service claims for that individual and all
designated dependants. A nine-digit Personal Health
Identification Number (PHIN) is used for payment of all
hospital services and for the provincial drug program.
As of March 31, 2013, there were 1,271,388 residents registered with the Manitoba Health Services Insurance Plan.
There is no provision for a resident to opt out of the
Manitoba Health Plan.
3.2 Other Categories of Individuals
The Residency and Registration Regulation (M.R. 54/93,
sub-section 8(1)) requires that temporary workers possess a
work permit issued by Citizenship and Immigration Canada
for at least 12 consecutive months, be physically present in
Manitoba for six months in a calendar year, and be legally
entitled to be in Canada before receiving Manitoba Health
coverage.
Section 8.1(a.1) was added to the Residency and Registration
Regulation in 2012 to extend 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 was added to the Residency and Registration
Regulation in 2013 to extend deemed residency to temporary foreign workers (and their dependants) in the province
to provide agricultural services on the basis of a work
permit, regardless of the duration of their work permit.
4.0 PORTABILITY
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.
76
4.2 Coverage During Temporary Absences in Canada
The Residency and Registration Regulation (M.R. 54/93
section 7(1)) defines the rules for portability of health
insurance during temporary absences in Canada.
Students are considered residents and will continue to
receive health coverage for the duration of their fulltime 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 services incurred in all provinces
or territories are paid through a reciprocal billing agreement
at host province or territory rates. Claims for medical services
received in Quebec are submitted by the patient or physician
to Manitoba Health for payment at host province rates.
4.3 Coverage During Temporary Absences
Outside Canada
The Residency and Registration Regulation (M.R. 54/93,
sub-section 7(1)) defines the rules for portability of health
insurance during temporary absences from Canada.
Section 7(1)(g) was added to the Residency and Registration
Regulation in 2013, extending 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 Manitoba Health coverage for up to 24 consecutive months. Individuals must return and reside in Manitoba
after completing their employment terms. Clergy serving
as humanitarian aid workers or missionaries on behalf of a
religious organization approved as a registered charity under
the Income Tax Act (Canada) will be covered by Manitoba
Health 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 Manitoba Health for up
to 24 consecutive months. These individuals also must return
and reside in Manitoba after completing their leave.
Canada Health Act — Annual Report 2012–2013
Chapter 3: MANITOBA
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
Manitoba Health 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 Manitoba Health
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 require prior approval from Manitoba Health.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
Manitoba Health ensures that medical services are
equitable and reasonably available to all Manitobans.
Effective January 1, 1999, the Surgical Facilities
Regulation (M.R. 222/98) under the Health Services
Insurance Act came into force to prevent private
surgical facilities from charging additional fees for
insured medical services.
The Health Services Insurance Act, the Private Hospitals
Act and the Hospitals Act include:
• definitions and other provisions to ensure that no
charges can be made to individuals who receive
insured surgical services or to anyone else on that
person’s behalf; and
• that a surgical facility cannot perform procedures
requiring overnight stays and thereby function as
a private hospital.
Manitoba Health continues to invest in improving clients’
access. In 2010, Manitoba made a commitment that all
Manitobans will have access to a family physician by 2015.
To achieve this goal, Manitoba invested in new initiatives
such as Primary Care Networks (including teams), opened
the fourth Quick Care Clinic, 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
Canada Health Act — Annual Report 2012–2013
Links-Info Santé service). Since 2008, Manitoba Health
funded and co-ordinated over 50 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 2012–2013 eight primary care clinics and three regional
community programs completed the training.
In October, 2012, mobile ultrasound was established for the
Russell/Roblin area which resulted in the ability to double
the mobile ultrasound capability and allow for increased
capacity in Swan River and Roblin.
In October, 2012, computed radiography facilities were
replaced in LacDuBonnet, Pine Falls and Beausejour. This
new equipment utilizes digital imaging rather than film
processing resulting in patients receiving their test results
faster and physicians having improved access to imaging
to enhance patient treatment planning.
In 2012–2013, additional pathologists and technologists
were hired throughout the province to support Diagnostic
Services of Manitoba (DSM) to achieve College of American
Pathologist (CAP) Accreditation.
In November 2012 the province released an updated
framework “Manitoba’s Cancer Strategy 2012–2017”
for cancer control that will guide actions to build on the
major successes delivered under the 2007 provincial cancer
strategic framework. The document, created with input
from partners, stakeholders and cancer patients themselves,
outlines an integrated and cohesive approach to cancer that
involves prevention, screening, diagnosis, treatment, palliative care and survivorship. Key activities to date include:
• Establishment of an advanced diagnostic machine that
analyzes the genetic make-up of breast cancer cells to
help determine the best treatment for breast cancer was
announced. Previous breast tissue samples that were sent
out-of-province for the HER–2 diagnostics can now be
done in Manitoba thus significantly reducing the wait
time for results.
• Announcement of a multi-million dollar project to
convert all analog mammogram machines across the
province to digital equipment. Manitoba will also
invest in the necessary technology to ensure the new
digital mammograms can be viewed and analyzed by
health care providers across the province, ensuring a
seamless use of these images for patient care, regardless
of location.
The Cancer Patient Journey initiative was established
in 2011 to streamline cancer services and dramatically
reduce the wait time for patients between the time cancer
is suspected and the start of effective treatment to two
months or less. Key initiative activities to date include:
77
Chapter 3: MANITOBA
• Hiring, training and deployment of Rapid Improvement
Leads (RIL’s) that are Lean Six Sigma trained improvement specialists. The RILs work with front line health
care professionals in diagnostic imaging, pathology,
surgery, primary care, and medical/radiation oncology
to assess current process, and identify areas for improvements in access and wait times. The following disease
sites have been prioritized for focused analysis and
targeted improvements as follows:
•
•
•
•
•
•
Breast
Colorectal
Lung
Prostate
Lymphoma
All other
• Announcement of four Regional Cancer Program Hubs to
be located in Brandon, Selkirk, Steinbach and Thompson.
CancerCare Manitoba (CCMB) in partnership with the
Regional Health Authorities is in the process of expanding
seven of the sixteen Community Cancer Programs, which
are rural oncology outpatient units focused on delivering
chemotherapy, to become Regional Cancer Care Program
Hubs. In addition to the current chemotherapy services,
these Hubs will provide navigation services, psychosocial
support, and enhanced access to clinical expertise in an
effort to expedite cancer diagnosis and treatment for
people living outside of Winnipeg.
In acute care and diagnostic services, initiatives such as
Releasing Time to Care and Lean Six Sigma were implemented to improve patient flow and patient access, along
with wait list management activities and enhanced service
funding to reduce backlogs. The Patient Access Registry
Tool, an electronic booking request and wait-time/wait list
management system, is being actively used in the Winnipeg
Regional Health Authority (WRHA) for elective adult and
pediatric surgery.
Funding to enhance volume of services has been sustained
and increased. Manitoba continues to work with its regional
health authority partners in exploring and implementing
improved access models, and investigating demand manage­
ment strategies, including improved appropriateness
of services.
Manitoba continues to have growth in the number of active
practicing nurses. There were 17,578 active practicing nurses in
Manitoba in 2013 which is a net gain of 390 nurses over 2012.
The Nurses Recruitment and Retention Fund contributes
significantly to improving the nursing supply in Manitoba
through initiatives such as: increasing nursing education
seats; relocation cost reimbursement; the Conditional
Grant Program, which encourages new graduates to work
in rural and northern regions; the personal care home
grant; and funding for continuing education and specialty
78
education programs. Collaborative efforts and financial
support will also continue to address accessibility for
internationally educated nurses to establish their careers
in Manitoba. In addition, recent amendments to the
Extended Practice Regulation now allows nurses on the
register to independently prescribe drugs, order screening
and diagnostic tests, and perform minor surgical and
invasive procedures as set out in regulation. The number
of nurses on the Extended Practice register has grown
from four in 2005 to 118 in 2012.
Manitoba continues to experience increases in the number of
new physicians registering with the licensing body. Manitoba
continues to provide grants to medical students, providing
recipients with financial assistance in each of their four years
of medical school. Each grant requires a commitment to
return service to under-serviced populations upon graduation.
The Province also provides a provincial specialist fund
and resettlement fund to practicing physicians who
choose to move to underserviced areas of the Province.
The Resettlement Fund is open to both family practitioners and specialists.
5.2 Physician Compensation
Manitoba continues to employ the following methods of
payment for physicians: fee-for-service, contract, blended
and sessional. The Health Services Insurance Act governs
remuneration to physicians for insured services. There were
no amendments to the Health Services Insurance Act related
to physician compensation during the 2012–2013 fiscal year.
Fee-for-service remains the dominant method of payment
for physician services. Notwithstanding, alternate payment
arrangements constitute a significant portion of the total
compensation to physicians in Manitoba. Alternate-funded
physicians are those who receive non fee-for-service compensation, including through a salary (employment relationship)
or those who work on an independent contract basis.
Manitoba also uses blended payment methods 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 sessional payments for providing
medical services on a time based arrangement, as well as
stipends for on-call and other responsibilities.
Manitoba Health represents Manitoba in negotiations
with physicians. The physicians are typically represented
by Doctors Manitoba with some notable exceptions, such
as oncologists.
The current Master Agreement between Doctors Manitoba
and Manitoba has an effective date from April 1, 2011 to
March 31, 2015.
The Physician’s Manual, a billing and fee guide, provides
Manitoba physicians with a listing of medical services that
are insured by Manitoba Health. Five main system data
Canada Health Act — Annual Report 2012–2013
Chapter 3: MANITOBA
checks and processes within the Manitoba Health mainframe 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 quasijudicial tribunal, hears appeals if a person is not satisfied with
certain decisions of Manitoba Health or is denied entitlement
to a benefit under the Health Services Insurance Act.
5.3 Payments to Hospitals
Division 3.1 of Part 4 of the Regional Health Authorities
Act sets out the requirements for operational 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 this division, 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,
the funding to be provided by the regional health authority
for the health services, the term of the agreement, and 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.
There are three regional health authorities which have hospitals operated by health corporations in their health regions.
The regional health authorities have concluded the required
agreements with health corporations. The operating agreements 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
Canada Health Act — Annual Report 2012–2013
Health Authorities Act. Section 23 of the Act requires
that regional health authorities allocate their resources
in accordance with the approved regional health plan.
The allocation of resources by regional health authorities for
providing hospital services is approved by Manitoba Health
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.
Pursuant to subsection 50(2.1) of the Health Services
Insurance Act, payments from the Medical Health Services
Insurance Plan 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.
No legislative amendments to the Act or the regulations
in 2012–2013 had an effect on payments to hospitals.
6.0 RECOGNITION GIVEN TO
FEDERAL TRANSFERS
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 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.
79
Chapter 3: MANITOBA
Registered Persons
1. Number as of March 31st (#).1
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
1,209,401
1,228,246
1,230,270
1,265,059
1,271,388
Insured Hospital Services Within Own Province or Territory
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#).
5. Payments to private for-profit facilities
for insured health services ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
97
96
96
96
96
not available
not available
not available
not available
not available
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
1
1
1
1
1
1,553,438
1,570,832
1,541,540
2,005,150
1,928,985
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
3,280
2,626
2,844
2,899
2,690
24,489,298
21,612,535
27,092,558
26,478,561
25,548,935
35,957
28,729
30,983
29,070
31,270
9,662,718
8,655,118
10,454,203
10,706,338
10,073,238
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
658
552
634
646
628
3,252,651
1,924,044
2,454,364
1,913,457
4,317,523
10,121
10,097
10,706
11,311
11,408
2,650,500
2,954,321
3,022,630
3,226,581
3,193,548
1. Population as of March 31, 2012
80
Canada Health Act — Annual Report 2012–2013
Chapter 3: MANITOBA
Insured Physician Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
2,073
2,121
2,276
2,322
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 ($).
789,101,000
843,087,000
920,890,000
927,916,000 988,164,000
18.Total payments for services provided by
physicians paid through fee-for-service ($).
476,227,782
552,890,200
553,924,806
595,083,828
593,129,217
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 ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
243,881
237,192
267,122
231,683
238,400
9,721,570
10,287,990
9,909,927
10,989,977
11,127,080
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
7,446
6,768
7,226
8,285
7,984
725,382
627,563
953,272
703,353
1,148,432
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
Canada Health Act — Annual Report 2012–2013
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
131
135
133
131
160
4,833
5,950
5,475
5,290
5,236
1,175,314
1,701,655
1,522,545
1,468,524
1,231,972
81
82
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
Saskatchewan
Introduction
1.0 PUBLIC ADMINISTRATION
Through leadership and partnership, the Ministry of Health
is committed to providing high-quality health care to the
people of Saskatchewan through a responsive, efficient,
and patient- and family-centered health care system. The
Ministry’s priority is a health system that puts patients and
families first, and provides the best possible health care.
1.1 Health Care Insurance Plan and Public Authority
The health care system in Saskatchewan is multi-faceted
and complex. To ensure the provision of essential and
appropriate services, the Ministry establishes provincial
strategy and policy direction, sets and monitors standards,
and provides funding.
The Ministry also works in partnership with organizations
at the local, regional, provincial, national and international
levels to provide Saskatchewan residents with access to
quality health care. The Ministry oversees a health care
system that includes 12 regional health authorities (RHAs),
the Saskatchewan Cancer Agency (SCA), the Athabasca
Health Authority, affiliated health care organizations and
a diverse group of professionals, many of whom are in
private practice.
There are 26 self-regulated health professions in the province and the health system as a whole employs more than
40,000 people who provide a broad range of services. The
Ministry supports the RHAs, SCA and other stakeholders to
recruit and retain health care providers, including nurses and
physicians. The Ministry is also responsible for approximately
50 different pieces of legislation.
The Ministry is organized into: Medical Services
and Surgical/Acute Line; Primary and Rural Health
Services; Mental Health and Community Services;
and Corporate Services. The Strategy and Innovation
Branch; Communications Branch, Nursing Secretariat
and Labour Relations unit report directly to the
Deputy Minister.
For more information about the Ministry’s programs
and services, please visit the Ministry of Health website
at: www.health.gov.sk.ca.
Canada Health Act — Annual Report 2012–2013
The provincial government is responsible for funding and
ensuring the provision of insured hospital, physician and
surgical-dental services in Saskatchewan. Section 6.1 of
the 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
• make grants or provide subsidies to stimulate and
develop public health research, and to conduct surveys
and studies in the area of public health.
Sections 8 and 9 of the Saskatchewan Medical Care
Insurance Act provide the authority for the Minister of
Health to establish and administer a plan of medical care
insurance for residents. The Regional Health Services Act,
implemented in 2002, provides the authority to establish
12 regional health authorities.
Sections 3 and 9 of the Cancer Agency Act provide for
establishing a Saskatchewan Cancer Agency and for the
Agency to coordinate a program for diagnosing, preventing
and treating cancer.
The mandates of the Ministry of Health, regional health
authorities and the Saskatchewan Cancer Agency are
outlined in the 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.
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 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.
2.0 COMPREHENSIVENESS
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 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.
The most recent audits were for the year ending
March 31, 2013.
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.
The audits of the Government of Saskatchewan, regional
health authorities and Saskatchewan Cancer Agency are
tabled in the Saskatchewan Legislature each year. The
Hospitals are grouped into the following five categories: Community Hospitals; Northern Hospitals; District
Hospitals; Regional Hospitals; and Provincial Hospitals,
Section 34 of the Cancer Foundation Act prescribes that
the records and accounts of the Saskatchewan Cancer
Foundation shall be audited at least once a year by the
Provincial Auditor or by a designated representative.
84
Canada Health Act — Annual Report 2012–2013
Chapter 3: Saskatchewan
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:
• 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, 2013, there were 2,044 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, 2013, there were no opted-out physicians
in Saskatchewan.
Canada Health Act — Annual Report 2012–2013
Insured physician services are those that are medically
necessary, are covered by the Medical Services Plan of the
Ministry of Health, and are listed in the Physician Payment
Schedule of the Saskatchewan Medical Care Insurance
Payment Regulations (1994) of the Saskatchewan Medical
Care Insurance Act.
A process of formal discussion between the Medical Services
Plan and the Saskatchewan Medical Association addresses
new insured physician services and definition or assessment
rule revisions to existing selected services. The Executive
Director of the Medical Services Branch manages this process. When the Medical Services Plan covers a new insured
physician service, or revisions to definitions or assessment
rules for existing services occur, a regulatory amendment is
made to the Physician Payment Schedule.
Although formal public consultations are not held, any
member of the public may make recommendations about
physician services to be added to the Medical Services Plan.
2.3 Insured Surgical-Dental Services
Dentists may opt out or not participate in the Medical
Services Plan, but if doing so, they must opt out of all
insured surgical-dental 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, 2013.
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.
85
Chapter 3: Saskatchewan
2.4 Uninsured 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; surgical-dental services
that are not medically necessary; and services received
under other public programs including the Workers’
Compensation Act, the federal Department of Veteran
Affairs and the Mental Health Services Act.
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.
3.0UNIVERSALITY
3.1 Eligibility
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-inCouncil 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 and the Royal
Canadian Mounted Police (RCMP), federal inmates
and refugee claimants; visitors to the province1; 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 and the
RCMP2, 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, 2012, was 1,090,953.
1. On June 29, 2012, as a result of the federal Jobs, Growth and Long-term Prosperity Act, the Canada Health Act was amended to allow members of the
RCMP to be eligible for coverage under provincial and territorial health plan, effective April 2013.
2. See footnote 1
86
Canada Health Act — Annual Report 2012–2013
Chapter 3: Saskatchewan
3.2 Other Categories of Individuals
• employment of up to 12 months (no documentation
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.
• vacation and travel of up to 12 months.
Refugees are eligible on confirmation of Convention status
combined with a study/work permit, Minister’s permit or
permanent resident, that is, landed immigrant, record.
On June 30, 2012 there were 12,852 such temporary residents registered with the Saskatchewan Ministry of Health.
4.0 PORTABILITY
4.1 Minimum Waiting Period
In general, insured persons from another province or territory
who move to Saskatchewan are eligible on the first day of the
third month following establishment of residency. However,
where one spouse arrives in advance of the other, the eligibility for the later arriving spouse is established on the earlier
of a) the first day of the third month following arrival of the
second spouse; or b) the first day of the thirteenth month
following the establishment of residency by the first spouse.
4.2 Coverage During Temporary Absences in Canada
Section 3 of The Medical Care Insurance Beneficiary and
Administration Regulations of the Saskatchewan Medical
Care Insurance Act prescribes the portability of health
insurance provided to Saskatchewan residents while temporarily absent within Canada. There were no changes to the
in-Canada temporary absence provisions in 2012–2013.
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.
Continued coverage during a period of temporary absence
is conditional upon the registrant’s intent to return to
Saskatchewan residency immediately on expiration of the
approved absence period as follows:
• education: for the duration of studies at a recognized
educational facility (confirmation by the facility of
full-time student status and expected graduation date
are required); Canada Health Act — Annual Report 2012–2013
required); and
Saskatchewan has bilateral reciprocal billing agreements with
all provinces for hospital services, and all but Quebec for
physician services. Payment for publicly funded Quebec physician services is made at Saskatchewan rates (Saskatchewan
Physician Payment Schedule).
4.3 Coverage During Temporary Absences
Outside Canada
Section 3 of the Medical Care Insurance Beneficiary and
Administration Regulations of the Saskatchewan Medical
Care Insurance Act prescribes the portability of health
insurance provided to Saskatchewan residents who are
temporarily absent from Canada.
Continued coverage for students, temporary workers, and
vacationers and travellers during a period of temporary
absence from Canada is conditional on the registrant’s
intent to return to Saskatchewan residence immediately
on the expiration of the approved period as follows:
• education: for the duration of studies at a recognized
educational facility (confirmation by the facility of
full-time student status and expected graduation date
are required);
• contract employment of up to 24 months; and
• vacation and travel of up to 12 months.
Section 3 of the Medical Care Insurance Beneficiary and
Administration Regulations provides open-ended temporary
absence coverage for persons whose principal place of residence is in Saskatchewan, but who are not able to satisfy the
annual six months physical presence requirement because
the nature of their employment requires travel from place
to place outside Canada (e.g., cruise line workers).
Section 6.6 of the 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.
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 a reciprocal billing arrangement. This
arrangement means that residents do not need prior approval
87
Chapter 3: Saskatchewan
and may not be billed for most services received in other
provinces or territories while travelling within Canada. The
cost of travel, meals and accommodation are not covered.
Prior approval is required for the following services provided
out-of-province:
• alcohol and drug, mental health, rehabilitation and
problem gambling services.
Prior approval from the Ministry must be obtained by the
patient’s specialist.
Out-of-Country
Prior approval is required for the following services provided
outside Canada:
• 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 outof-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
surgical-dental 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 will guide 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. The four year plan is in response
to recommendations in the Patient First Review, and was
developed with assistance from stakeholder advisory groups.
It is designed to improve the patient’s experience across the
88
entire continuum of care — from initial contact with a health
provider, to surgery, to recuperation in the community.
The plan is based on five objectives: 1) shorter waits for
surgical care; 2) a better experience for patients and families; 3) safe, high quality care; 4) support for good health,
and 5) patient-centred providers. Supporting the objectives
are 31 initiatives such as increasing surgical procedures
and diagnostic imaging services, offering opportunities for
greater patient choice, mechanisms to improve safety, health
promotion and injury prevention activities, and initiatives
to support an effective health work force.
As of March 31, 2013, there were 2,044 physicians licensed
to practice in the province and eligible to participate in the
Medical Care Insurance Plan. Of these, 1,066 (52.2 percent) were family practitioners and 978 (47.8 percent)
were specialists.
As of March 31, 2013, there were approximately
418 practising dentists and dental surgeons located in
all major centres in Saskatchewan. Eighty-eight 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
province-wide physician shortages. In 2012–2013 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.
Post-graduate seats were offered in Regina, Prince Albert
and Swift Current.
• The Physician Recruitment Agency of Saskatchewan
(saskdocs), which was created in 2009, continued to
provide recruitment expertise to communities, physician
practices and health agencies.
• The Saskatchewan International Physician Practice
Assessment program, which worked to ensure that
foreign-trained physicians are assessed with sufficient
rigor to ensure patients receive safe, high-quality care
while meeting the needs of communities and health
regions recruiting physicians.
In addition to the initiatives noted above, the Ministry
provides various practicing establishment grants, training
grants, and residency positions in exchange for return-ofservice commitments. The Ministry funds compensation
mechanisms for emergency room coverage to ensure
patients have access to emergency medical services.
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.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Saskatchewan
• 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-term 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.
Section 6 of the Saskatchewan Medical Care Insurance
Payment Regulations (1994) outlines the obligation of the
Minister of Health to make payments for insured services
in accordance with the Physician Payment Schedule and
the Dentist Payment Schedule.
Fee-for-service is the most widely used method of compensating physicians for insured health services in Saskatchewan,
although sessional payments, salaries, capitation arrangements 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 2012–2013 amounted
Canada Health Act — Annual Report 2012–2013
to $823.7 million: $480.2 million for fee-for-service billings;
$30.3 million for Specialist Emergency Coverage Programs;
and $313.2 million in non-fee-for-service expenditures. There
was also an additional $42.4 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.
6.0 RECOGNITION GIVEN TO
FEDERAL TRANSFERS
The Government of Saskatchewan publicly acknowledged
the federal contributions provided through the Canada
Health Transfer in the Ministry’s 2012–2013 Annual Report,
the Government of Saskatchewan 2012–2013 Budget and
related documents, its 2012–2013 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.
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Chapter 3: Saskatchewan
Registered Persons
1. Number as of March 31st (#).
2008–2009
2009–2010
2010–2011
2011–2012
1,035,544
1,036,284
1,070,477
1,084,127
2012–2013
3
1,090,953
3
Insured Hospital Services Within Own Province or Territory
Public Facilities1
2. Number (#).
3. Payments for insured health services ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
67
67
66
66
66
1,402,109,000
4
1,556,078,000
4
1,636,013,000
4
1,694,858,000
4
1,777,208,000
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
4. Number of private for-profit facilities
providing insured health services (#).
0
0
3
5
4
5. Payments to private for-profit facilities
for insured health services ($).
0
0
Not Available
Private For-Profit Facilities
5
Not Available
5
Not Available
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
4,365
5,722
4,304
5,258
5,433
43,631,600
53,119,000
48,700,300
51,418,800
54,483,700
65,274
71,123
67,689
65,916
74,201
17,936,200
21,497,100
21,282,400
22,268,800
26,716,300
388
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
251
398
295
400
1,637,300
2,755,200
3,401,000
8,186,600
1,437
2,189
1,992
2,646
1,938
1,468,500
1,810,000
1,796,700
3,203,800
1,511,300
6
2,007,000
3. Saskatchewan’s numbers as of June 30, 2012.
4. This number includes estimated government funding to Regional Health Authorities (RHAs) in their annual audited financial statements.
— Includes acute care services, specialized hospital services, and in-hospital specialist services.
— Does not include inpatient mental mental health, or addiction treatment services.
— Does not include payments to Saskatchewan Cancer Agency for out-patient chemotherapy and radiation.
5. Private facilities providing surgical services and computed tomography scans receive payments for these services under contract with Regional Health
Authorities. The Ministry of Health does not provide payments to these facilities.
6. Increase in 2011–12 was due to a cluster of high cost procedures Saskatchewan residents received in the United States.
90
Canada Health Act — Annual Report 2012–2013
4
5
Chapter 3: Saskatchewan
Insured Physician Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
1,836
1,882
1,946
1,985
2,044
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($).
630,253,960
651,437,652
714,441,498
794,901,943
823,656,225
18.Total payments for services provided by
physicians paid through fee-for-service ($).
401,135,717
14.Number of participating physicians (#).
7,8
410,875,422
7,8
457,194,531
7,8
457,307,474
7
480,173,762
7
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
599,106
586,621
610,328
623,778
659,994
27,753,524
29,037,662
31,505,813
32,103,002
33,658,928
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
not available
not available
not available
not available
not available
647,700
1,299,600
1,324,100
2,279,100
1,199,100
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
79
70
85
93
88
18,085
22,349
17,800
17,420
18,123
1,840,276
2,013,007
1,827,088
1,719,770
1,710,397
7. Figure is composed of fee-for-service billing and funding for the Emergency Rural Coverage Program which is paid through the fee-for-service program.
8. Figures have been revised to be consistent with the Annual Statistical Report (2008–09 to 2010–11).
Canada Health Act — Annual Report 2012–2013
91
92
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
Alberta
Introduction
Alberta’s Health Care System
The Minister of Health, the Department of Health (Alberta
Health) and Alberta Health Services are key elements in
Alberta’s health care system. All agencies work together to
deliver better care, improve health outcomes and provide
the best health care system possible for Albertans.
The vision of Alberta Health, Healthy Albertans in a Healthy
Alberta, is achieved through a commitment to the mission,
core business and goals of the ministry. As outlined in Alberta
Health’s 2012–2013 Annual Report, Alberta Health’s core
business activities involve improving Albertans’ health status
over time through effective leadership and sound governance
of Alberta’s health system. Over the past year, working with
Alberta Health Services, Alberta Health has made significant
progress towards achieving four key goals:
Goal 2: Strengthened public health and healthy living
• Implementation of Creating Connections: Alberta’s
Addiction and Mental Health Action Plan 2011–2016
began in 2012, to reduce the prevalence of addiction
and mental illness and to provide quality assessment,
treatment and supportive services. Late 2012 saw the
opening of two 20-bed units at the Alberta Hospital
Edmonton; increased funding to enhance addiction and
mental health services for homeless Albertans in Calgary,
Edmonton and Lethbridge; and the release of “Creating
Tobacco-free Futures — Alberta’s Strategy to Prevent
and Reduce Tobacco Use, 2012–2022.”
• In 2012–2013, Albertans had more health professionals
and more locations offering influenza immunization than
ever before. Almost 900,000 Albertans were immunized
over a six week period. The number of pharmacists and
other community partners offering the influenza vaccine
to Albertans doubled in 2012–2013.
Goal 1: Enhanced health system accountability
and performance
Goal 3: Appropriate health workforce development
and utilization
• In July 2012, the Minister formed the Health System
• In April 2012, three pilot Family Care Clinics (FCCs)
Governance Review Task Force to advise on the roles,
responsibilities and accountabilities in the health system.
Following interviews with over 60 stakeholders and
literature reviews, the Task Force tabled its report.
• Throughout 2011–2012 and 2012–2013, Alberta Health,
Alberta Infrastructure and Alberta Health Services have
been working to improve and standardize the capital
project delivery processes.
• The following are key major capital projects which
started clinical operations in 2012–2013:
• Opened two new ambulatory facilities, the Kaye
Edmonton Clinic and the East Calgary Health Centre.
• Completed the expansion of the following acute
care projects: two hospitals in Calgary: the Foothills
Medical Centre and the Rockyview General Hospital;
the expansion of the Sturgeon Community Hospital
in St. Albert; and a new orthopedic surgical facility at
the Royal Alexandra Hospital.
were opened in Edmonton, Calgary, and Slave Lake.
These clinics have shown promising results in their first
year of operation, including seeing thousands of new
patients and decreasing non-urgent visits to hospital
emergency departments. Initial evaluations of the three
FCC sites indicate approximately 4,000 previously
unattached Albertans are now attached to a FCC. All
FCC clients have access to interdisciplinary teams to
better manage patient care.
• In January 2013, work began on further evolving the
highly successful Primary Care Network (PCN) model.
Alberta Health began work with the Primary Care
Alliance and Alberta Health Services to develop a plan
for the future evolution of PCNs, to provide individuals
with a more standard and broader range of services from
PCNs. As of March 31, 2013, there were 40 PCNs in
Alberta, including more than 2,600 family physicians
providing primary care to over 2.9 million Albertans.
• Opened the new South Health Campus (Calgary) in
the fall of 2012, with phasing of the clinical services
to continue over the next few years.
Canada Health Act — Annual Report 2012–2013
93
Chapter 3: ALBERTA
Goal 4: Excellence in health care
• In February 2013, Changing Our Future: Alberta’s Cancer
Plan to 2030 was released as a long-term, strategic plan
for creating a high performing system of excellence for
cancer care and prevention within the province. The plan
identifies current challenges and describes the transformative shifts needed by 2030 to realize Alberta’s vision
of becoming a place where most cancers are prevented,
more cases of cancer are cured, and the suffering of
people affected by cancer is dramatically reduced.
• In 2012–2013, the integration of diagnostic images and
associated reports from community providers to Netcare,
Alberta’s electronic health record, was completed. The
first pilot of end to end integration between Netcare’s
Pharmaceutical Information Network and a community
physician’s Electronic Medical Record system, as well as
a pharmacist’s Pharmacy Practice Management System
was also successfully completed.
• Relative to the previous year, in 2012–2013 the number
of individuals waiting in the community for continuing
care beds has been reduced from 1,002 to 701; exceeding
the target of 850. This reduction is likely due to the
creation of 857 new continuing care beds and the
additional $25 million in funding to support home
care projects across the province.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and Public Authority
Alberta Health administers 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 Health on May 31,
94
2013 and indicated that the statements fairly represent, in
all material respects, the financial position and results of
operations for the year ended March 31, 2013.
2.0 COMPREHENSIVENESS
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) regulate the provision of insured services by
hospitals or designated non-hospital surgical facilities. A
directory of approved hospitals in Alberta can be found at:
www.health.alberta.ca/services/health-benefits-services.html.
During 2012–2013, 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 treatment services for in-patients
and out-patients, to the routine care and management
of patients with previously diagnosed chronic conditions. The benefits available to hospital patients in
Alberta are established in the Hospitalization Benefits
Regulation (AR 244/1990). The Regulation is available
at: www.health.alberta.ca/about/health-legislation.html.
There is no regular process to review insured hospital
services, as the list of insured services included in the
regulations is intended to be both comprehensive and
generic, and does not require routine review and updating.
Changes to specific physician services can be found in the
Schedule of Medical Benefits, and are described in the
next section.
2.2 Insured Physician Services
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 Alberta
Health Care Insurance Act are permitted to provide insured
services under the Alberta Health Care Insurance Plan.
Alberta had 8,100 physicians participating under the
Alberta Health Care Insurance Plan as of March 31, 2013.
Within this 6,655 physicians were paid exclusively under
fee-for-service (FFS), 719 were compensated solely under
an Alternative Relationship Plan (ARP) and the remaining
726 physicians received compensation from both FFS and
ARP. Out of the 8,100 physicians, 2,995 were registered
providers in PCNs as of March 31, 2013.
Canada Health Act — Annual Report 2012–2013
Chapter 3: ALBERTA
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 of the Alberta Health Care Insurance Plan by notifying
the Minister in writing indicating the effective date of the
opting out, publishing a notice of the proposed opting out in
a newspaper having general circulation in the area in which
the physician practices, and 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. A physician who has opted-out
must post a notice in part of the physician’s office to which
patients have access, advising patients of the physician’s
opted-out status, and ensuring that each patient is advised
of their opted-out status before any service is provided to the
patient. By opting out of the Alberta Health Care Insurance
Plan, a physician agrees that, commencing with the opt-out
effective date, they will not participate in the publicly funded
health system. This means the cost of health care services
they provide is the total responsibility of the patient. As of
March 31, 2012, there were zero opted-out physicians in
the province.
Section 12 of the Alberta Health Care Insurance Regulation
lists services which are not insured 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.
The Schedule of Medical Benefits is revised on a regular basis.
Effective April 1, 2012, three new health service codes for
facet joint injections were introduced and multiple amended
services were updated to modifier descriptions in the Schedule
of Medical Benefits. All changes to the Schedule of Medical
Benefits require Ministerial approval.
The Tri-lateral Master Agreement expired March 31, 2011.
A new bi-lateral agreement between Alberta Health and the
Alberta Medical Association was reached in April 2013.
This agreement is effective for a seven-year period from
April 1, 2011 to March 31, 2018.
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
Canada Health Act — Annual Report 2012–2013
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 of the plan by notifying the Minister of Health
in writing of the effective date of their opting out and by
ensuring that each patient is advised of their opted-out status
before any service is provided to the patient. By opting out
of the Alberta Health Care Insurance Plan, a dentist agrees
that, commencing with the opt-out effective date, they will
not participate in the publicly funded health system. This
means the cost of health care services they provide is the
total responsibility of the patient. As of March 31, 2013,
no dentists were opted-out of the Alberta Health Care
Insurance Plan.
2.4 Uninsured Hospital, Physician, and
Surgical-Dental Services
Section 12 of the Alberta Health Care Insurance Regulation
lists services which are not insured 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. Alberta’s policy for Preferred
Accommodation and Non-Standard Goods or Services
is available at: www.health.alberta.ca/newsroom/
pub-health-authorities.html.
The policy describes the Government of Alberta’s
expectations of Alberta Health Services and guides its
decision-making with respect to 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 Minister’s designate
regarding any goods or services that will be provided as
non-standard goods or services. They are also required
to 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.
95
Chapter 3: ALBERTA
3.0UNIVERSALITY
3.1 Eligibility
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. 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-by-case basis.
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, 2013, there were 4,068,062 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, 2013, there were 229 Alberta residents who
were opted-out of the Plan.
3.2 Other Categories of Individuals
Residents who are not eligible for coverage under the
Alberta Health Care Insurance Plan, but receive health
care coverage from the federal government, include:
Persons on an approved Canada entry permit who may be
eligible include those with Student or Employment Permits,
Temporary Resident Permits, and Visitor Records. There
were 86,612 people covered under these conditions as of
March 31, 2013.
• Members of the Canadian Armed Forces;
• Members of the Royal Canadian Mounted Police
4.0 PORTABILITY
• Persons serving a term in a federal penitentiary.
4.1 Minimum Waiting Period
Spouse/partner and dependents of the above are provided
with Alberta Health Care Insurance Plan coverage if they
are residing in Alberta.
Under the Alberta Health Care Insurance Plan, 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.
(RCMP) who are appointed to a rank1; and
The Alberta Health Care Insurance Plan covers persons
released from the RCMP, 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. During
2012–2013, no amendments were made to the legislation
regarding eligibility. The RCMP Health Coverage Statutes
Amendment Act, 2013 passed first reading on March 21,
2013, was given Royal Assent on April 29, 2013 and came
into force on April 1, 2013.
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. New residents in Alberta
should apply for coverage within three months of arrival
or effective dates may be affected. For persons moving from
within Canada, their registration is effective on the first day
of the third month after their arrival. For persons moving
4.2 Coverage During Temporary Absences in Canada
The Alberta Health Care Insurance Plan provides coverage
for eligible Alberta residents who temporarily leave Alberta
for other parts of Canada. A person is considered temporarily absent from Alberta if the person stays in another
province or territory for a period that will not exceed
12 consecutive months.
Individuals who are routinely absent from Alberta every
year normally need to 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.
Alberta participates in the interprovincial hospital and
medical reciprocal agreements. These agreements were
established to minimize complex billing processes and
1. As the RCMP Health Coverage Statutes Amendment Act, 2013 was given Royal Assent and came into force on April 1, 2013, effective April 1, 2013,
Alberta RCMP members are covered under the Alberta Health Care Insurance Plan.
96
Canada Health Act — Annual Report 2012–2013
Chapter 3: ALBERTA
to help ensure timely payments to physicians and hospitals
when they provide services to residents from other provinces
or territories. Quebec does not participate in the medical
reciprocal agreement. Under these agreements, Alberta pays
for insured services that Albertans receive in other parts of
Canada at the host provincial or territorial rates.
of Canada. Section 5 of the Medical Benefits Regulation
addresses payment of physician services obtained outside
of Canada. These sections were not amended in 2012–2013.
In 2012–2013, 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.
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.
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 2012–2013.
Prior application is required for elective services received
out-of-country and approval may only be given through the
Out-of-Country Health Services Committee for insured services that are medically required, are not experimental, and
are not available in Alberta or elsewhere in Canada.
4.3 Coverage During Temporary Absences
Outside Canada
4.4 Prior Approval Requirement
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
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 of Alberta.
All Alberta residents have access to provincially funded and
insured health services regardless of where they live in the
province. Within Alberta, there are two major metropolitan
zones, the Calgary zone and the Capital (Edmonton) zone,
which provide provincially-funded, province-wide services
to Alberta residents who need tertiary-level diagnostic and
treatment services.
Individuals who are routinely absent from Alberta every
year normally need to 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
notify Alberta Health of their permanent and principal
place of residence within the province.
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 for Alberta Health Services governs all
health services in the province, working in partnership
with Health to ensure all Albertans have equal access to
health services across the province.
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 is paid at a maximum of $473 per visit, with a limit
of one visit per day. 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 application 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/outside-coverage.html.
The Government 2013–2016 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:
Section 16 of the Hospitalization Benefits Regulation
addresses payment for hospital services obtained outside
• A new regional hospital in Grande Prairie, which will
Canada Health Act — Annual Report 2012–2013
• The redevelopment of the Medicine Hat Regional Hospital
and will include 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.
• 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.
include a state-of-the-art cancer centre.
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Chapter 3: ALBERTA
• Alberta government is committed to adding 5300 con-
tinuing care spaces over the 5 year period of March 2010
to March 2015.
• Family Care Clinics.
• There were no new Primary Care Networks (PCNs)
launched during 2012–2013. As of March 31, 2013,
there were 40 PCNs operating in Alberta.
5.2 Physician Compensation
The Alberta Health Care Insurance Act governs the payment
of physicians. Most physicians are compensated through
the Alberta Health Care Insurance Plan on a volume-driven,
fee-for-service (FFS) basis. Alternative Relationship Plans
(ARPs) for specialists and family physicians offer alternative compensation models to the FFS payment system.
ARPs contribute to better health outcomes by supporting
innovative health care delivery.
A new bi-lateral agreement between Alberta Health and the
Alberta Medical Association was reached in April 2013. This
agreement is effective for a seven year period beginning on
April 1, 2011. Any changes to physician compensation for
the provision of insured services are subject to negotiation.
The agreement establishes overall increases to compensation
under the FFS and ARP compensation types. Once overall
increases are established, by virtue of the negotiated agreement, the parties will undertake an allocation process in
which increases are divided between the 31 medical sections.
ARPs were initially established under the Tri-Lateral
Master Agreement and since April 1, 2011 ARPs have
continued through Ministerial Order. 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 they offer an
alternative funding model to the way government has
traditionally funded health care service delivery.
Beyond matters of compensation for the provision of
insured services, the Tri-lateral Master Agreement also
contained provisions for programs involving patient access
and service improvements. The Agreement established
the Primary Care Initiative under which PCNs received
funding. PCNs support innovative health care delivery and
use a team approach to coordinate care for their patients.
Family physicians work with Alberta Health Services to
better integrate health services by linking to regional services
such as home care. Family physicians also work with other
health care providers such as nurses, dieticians, pharmacists,
physiotherapists, and mental health workers who help to
provide services within the PCNs. Funding for PCNs, which
was extended by Health when the 2003–2011 agreement
98
expired, is not intended to compensate physicians for the
provision of insured services although physicians can receive
payment for uninsured services related to work done on
behalf of the PCN.
The new bi-lateral agreement also provides for payments
to physicians under a physician on-call program, direct
overhead payments, and rural incentive programs. As with
the majority of physicians, dentists performing oral surgical
services that are insured under the Alberta Health Care
Insurance Plan are compensated through the Plan on a FFS
basis. Alberta Health establishes fees through a consultation
process with the Alberta Dental Association and College.
5.3 Payments to Hospitals
The Regional Health Authorities Act governs the funding of
Alberta’s single regional health authority—Alberta Health
Services. Most insured hospital services in Alberta are funded
through a single base operating grant given to Alberta Health
Services. Funding is provided for insured services delivered in
mental health hospitals, community mental health services,
insured services in cancer hospitals and for cancer services
that patients receive in regional hospitals. In addition, highly
specialized province-wide services are provided to all Alberta
residents in hospitals in Edmonton and Calgary.
Alberta’s Health Care Protection Act governs the provision
of insured surgical services performed in non-hospital surgical facilities. Ministerial approval of a contract between
the facility and/or operator and Alberta Health Services is
required in order for the facility to provide insured services.
Ministerial designation of a non-hospital surgical facility
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 contractual 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;
• the proposed surgical services will not have a negative
impact on the province’s public health system;
• there will be an expected benefit to the public;
• Alberta 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
Medical Profession Act and bylaws.
Canada Health Act — Annual Report 2012–2013
Chapter 3: ALBERTA
6.0 RECOGNITION GIVEN TO FEDERAL
TRANSFERS
The Government of Alberta publicly acknowledged the
federal contributions provided through the Canada Health
Transfer in its 2012–2013 publications.
Canada Health Act — Annual Report 2012–2013
99
Chapter 3: ALBERTA
Registered Persons
1. Number as of March 31st (#).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
3,589,494
3,692,001
3,786,238
3,910,117
4,068,062
Insured Hospital Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
226
223
225
225
226
not available
not available
not available
not available
not available
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
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 (#).2
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 ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
5,447
5,411
5,689
5,707
5,657
31,475,940
33,077,528
37,887,391
36,659,355
37,628,241
104,127
105,792
110,757
109,703
112,703
25,346,678
26,879,756
29,382,381
29,687,993
31,763,550
Insured Hospital Services Provided Outside Canada 3
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
4,762
4,506
3,075
3,613
4,921
4
446,718
425,269
294,509
339,343
472,489
4
4,305
4,544
3,425
4,414
5,461
4
291,836
306,639
267,120
467,081
440,188
4
2. The number of Public Facilities was re-calculated for the period 2008–2009 to 2011–2012 as 25 public health units were incorrectly registered as
Community Ambulatory Care Centres during this period.
3. This data does not include claims/payments for Alberta residents who have received health services out-of-country through the Out-of-Country Health
Services Committee application process.
4. Data reported for out-of-country hospital services are accurate as of June 30, 2013, however it does not reflect claims still being processed for 2012–2013.
100
Canada Health Act — Annual Report 2012–2013
Chapter 3: ALBERTA
Insured Physician Services Within Own Province or Territory5
14.Number of participating physicians (#).6
15.Number of opted-out physicians (#).
16.Number of non-participating physicians (#).
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
6,266
6,482
6,743
7,706
8,100
7
0
8
not applicable
8
not applicable
8
not applicable
0
8
8
0
0
0
0
0
not available
not available
not available
not available
not available
1,851,703,042
2,133,199,354
2,302,481,210
2,450,159,476
2,584,944,346
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
696,639
599,596
611,503
616,786
751,061
22,614,491
24,621,807
25,340,583
27,960,901
27,940,698
Insured Physician Services Provided Outside Canada 9
21.Number of services (#).
22.Total payments ($).
22,817
22,070
15,654
42,643
10
not available
11
1,245,840
1,266,451
909,715
2,573,169
10
not available
11
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
202
212
207
218
224
18,705
18,963
21,052
20,784
23,014
4,479,725
4,847,467
5,747,026
6,293,750
7,077,327
5. Data for for this table is processed three months after the close of the fiscal year. Any data pertaining to expenditures and physicians processed after this
date is not reflected in the presented information.
6. 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 fee-for-service and alternative relationship plans. Prior years reflected physicians that were only paid under fee-for-service.
7. 6,655 of these are paid under fee-for-service, 719 under an Alternative Relationship Plan and the remaining 726 received compensation from both
fee-for-service and alternative relationship plans.
8. 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.
9. This data does not include Alberta residents who have received health services out-of-country through the Out-of-Country Health Services Committee
application process.
10. The 2011–2012 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.
11. Data for out of country physician services is still being processed for 2012–2013.
Canada Health Act — Annual Report 2012–2013
101
102
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
British columbia
INTRODUCTION
1.0 PUBLIC ADMINISTRATION
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.
1.1 HEALTH CARE INSURANCE PLAN
AND PUBLIC AUTHORITY
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. 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 services
and province-wide health programs.
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 2012–2013
Annual Service Plan Report:
www.bcbudget.gov.bc.ca/Annual_Reports/2012_2013/pdf/
ministry/hlth.pdf
Canada Health Act — Annual Report 2012–2013
The British Columbia Medical Services Plan (MSP) is
admini­stered by the British Columbia Ministry of Health
(the Ministry). MSP insures medically required services
provided by physicians and supplementary health care
practitioners, laboratory services, and diagnostic procedures. The Ministry sets goals, standards, and performance
agreements for health service delivery and works with
the six health authorities to provide quality, appropriate,
and timely health services to British Columbians. 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).
The Medical Services Commission (MSC) manages the
MSP on behalf of the Government of British Columbia in
accordance with the Medicare Protection Act (section 3)
and its Regulation. The purpose is to preserve a publiclymanaged and fiscally sustainable health care 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 function and mandate of the MSC is to facilitate
reasonable access to quality medical care, health care, 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 the British Columbia Medical
Association (BCMA), and three members from the public
jointly nominated by the BCMA and government.
In 2012–2013, the Medicare Protection Act and the Medical
and Health Care Services Regulation were amended to permit
British Columbians to be absent from the province for up
to seven months in a year, an increase from six months, for
vacation purposes. This change allows BC residents who are
outside the province for vacation purposes for six months,
to qualify for an additional one month absence per calendar
year for a total of up to seven months and remain eligible for
MSP coverage.
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Chapter 3: British Columbia
The Medical and Health Care Services Regulation was also
amended to:
• clarify that the MSP is not obligated to pay for diagnostic
services that are conducted pursuant to a referral from a
practitioner who is not enrolled in the MSP;
• remove the exclusion of members of the RCMP from
the MSP; and
• clarify that only net income shown on a Notice of Assess­
ment or Notice of Re-assessment from the Canada
Revenue Agency may be used for calculating income
for the purpose of applying for premium assistance.
1.2 Reporting Relationship
The Medical Services Commission is accountable to the
Government of British Columbia through the Minister of
Health; 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.
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 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).
In addition to the Annual Service Plan Report, the Ministry
reports through various 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 Medical Services Commission Annual Report, available
at: www.health.gov.bc.ca/msp/legislation/msc.html
1.3 Audit of Accounts
The Ministry is subject to audit of accounts and financial
transactions through:
• The Office of the Comptroller General (OCG) Internal
Audit and Advisory Services; the government’s internal
auditor. The Comptroller General determines the scope
of the internal audits and timing of the audits in consultation with the audit committee of the Ministry. The
OCG reports can be located on the following website
link: http://www.fin.gov.bc.ca/ocg/ias/Audit_Reports.htm
104
• The Office of the Auditor General (OAG) of British
Columbia is responsible for conducting annual audits
as well as special audits and reports. The OAG reports its
findings to the Legislative Assembly. The OAG initiates
its own audits and determines the scope of its audits. The
Public Accounts Committee of the Legislative Assembly
reviews the recommendations of the OAG and determines
if and when the Ministry has complied with the audit
recommendations.
The OAG’s annual audit of the Ministry’s accounts and
financial transactions are reflected in the OAG’s overall
review and opinion related to the BC Public Accounts,
which can be found at the following website link:
www.bcauditor.com/pubs/2013/special/
audit-opinions-are-important-discussion-qualified-audit-o
The OAG’s special audits and reports can be located at the
following link: www.bcauditor.com/pubs.
1.4 Designated Agency
The MSP of British Columbia requires premiums to be
paid by eligible residents. The monies were collected by
the Ministry of Finance during the 2012–2013 fiscal year.
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:
• Ombudsman Act (British Columbia).
• Business Practices and Consumer Protection Act
(British Columbia).
• Financial Administration Act (British Columbia).
• Freedom of Information Legislation: i.e., Freedom
of Information and Protection of Privacy Act (British
Columbia) including FOIPPA Inspections; the Personal
Information Protection Act (British Columbia) and the
equivalent federal legislation, if applicable.
Since 2005, the Ministry has contracted with MAXIMUS
Canada to deliver the operations of the 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.
Canada Health Act — Annual Report 2012–2013
Chapter 3: British Columbia
• HIBC submits monthly reports to the Ministry, reporting
performance on service levels to the public and health
care providers. HIBC also posts reports on its website on
the performance of key service levels.
• HIBC applies payments against fee items approved by the
Ministry. The Ministry approves all payments before they
are released.
2.0 COMPREHENSIVENESS
2.1 Insured Hospital Services
The Hospital Act and Hospital Act Regulation provide
authority for the Minister of Health to designate facilities
as hospitals, to license private residential care hospitals,
to approve the bylaws of hospitals, to inspect hospitals,
and to appoint a public administrator. This legislation also
establishes broad parameters for the operation of hospitals.
The Hospital Insurance Act and the Hospital Insurance
Act Regulations provide the authority for the Minister
of Health 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.
In 2012–2013, the Hospital Act Regulation and the
Hospital Insurance Act Regulations were amended to
permit nurse practitioners and dental surgeons to admit
and discharge from hospital.
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, or
nurse practitioner. 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. As
per the report guidelines, uninsured services are referred
to in Section 2.4 of this report.
When medically required, the following are provided to
beneficiaries who are in-patients in an acute or rehabilitation hospital:
• accommodation and meals at the standard level;
• necessary nursing service;
• drugs, biologicals, and related preparations which are
required by the patient and administered in hospital;
• laboratory and radiological procedures and related
interpretations;
• diagnostic procedures and the necessary interpretations,
as approved by the Minister;
• use of operating room, caseroom, anaesthetic facilities,
•
•
•
•
use of radiotherapy facilities;
use of physiotherapy facilities;
services of a social worker;
rehabilitation services including occupational and
speech therapy; and
• other required services approved by the Minister,
provided by persons who receive remuneration from
the hospital.
When medically required, the following are provided as
benefits under the Hospital Insurance Act or the Medicare
Protection Act to out-patients who are beneficiaries:
• emergency department services;
• diagnostic services (e.g., laboratory or radiological
procedures);
• use of operating room facilities;
• equipment and supplies used in medically necessary ser-
vices provided to the beneficiary, including anaesthetics,
sterile supplies, dressings, casts, splints, or immobilizers
and bandages;
• meals required during diagnosis and treatment;
• drugs and medications administered in a medicallynecessary service provided to the beneficiary; and
• any service provided by an employee of the hospital
that is approved by the Minister.
The services are provided to beneficiaries without charge,
with a few exceptions, such as incremental charges for
preferred (but not medically required) medical/surgical
supplies and nonstandard accommodation, 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 Medicare Protection Act (MPA). Section 13 provides
that practitioners (including medical practitioners and health
care 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.
routine surgical supplies, and other necessary equipment
and supplies;
Canada Health Act — Annual Report 2012–2013
105
Chapter 3: British Columbia
Unless specifically excluded, the following medical services
are insured as MSP benefits under the MPA in accordance
with the Canada Health Act:
• medically required services provided to “beneficiaries”
(residents of British Columbia who are enrolled in MSP
in accordance with section 7 of the MPA) by a medical
practitioner enrolled with MSP; and
• medically required services performed in an approved
diagnostic facility under the supervision of an enrolled
medical practitioner.
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 2012–2013, 9,947 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 to access the following services: acupuncturist,
massage therapist, physiotherapist, chiropractor, naturopath, and podiatrist (non-surgical services). The program
contributes $23.00 towards the cost of each patient visit
to a maximum of ten visits per patient per annum summed
across the six types of providers.
Physicians enrolled in MSP may choose to be opted-in
or opted-out. Opted-in physicians are physicians who are
enrolled in MSP under Section 13 of the Medicare Protection
Act 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 Medicare Protection Act 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 optedout physician may not charge a patient more for an insured
benefit than the prescribed MSP amount. In 2012–2013,
MSP had four 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 the British Columbia Medical
Association (BCMA), modifications to the Payment Schedule
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such as additions, deletions, or fee changes are made by the
MSC, upon advice from the BCMA. Physicians who wish to
modify the payment schedule must submit proposals to the
BCMA Tariff Committee. On recommendation of the Tariff
Committee, interim listings may be designated by the MSC
for new procedures or other services for a limited period of
time while definitive listings are established.
During fiscal year 2012–2013, physician services which
were added as MSP insured benefits included 34 new fee
items which reflect current practice standards, for example:
13 new fee items were introduced for the Section of Cardiac
Surgery, and eight new fee items were introduced for the
Section of Orthopaedics.
2.3 Insured Surgical-Dental Services
Surgical-dental services are covered by the MSP when
hospitalization is medically required for the safe and
proper completion of surgery and when they are listed
in the Dental Payment Schedule.
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 in good standing
with the College of Dental Surgeons and enrolled in MSP
may provide insured surgical-dental services in hospital.
There were 217 dentists enrolled with MSP in 2012–2013
(includes only oral surgeons, dental surgeons, oral medicine,
and orthodontist billing through FFS).
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Medical necessity, as determined by the attending physician
and hospital, is the criterion for public funding of 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 by the hospital; treatment for which WorkSafeBC,
the Department of Veterans Affairs, or any other agency
is responsible; services or treatment that the Minister,
Canada Health Act — Annual Report 2012–2013
Chapter 3: British Columbia
or a person designated by the Minister, determines, on a
review of the medical evidence, that the beneficiary does
not require; and excluded illnesses or conditions (i.e., in
vitro fertilization; cosmetic service solely for the alteration
of appearance; and reversal of previous sterilization procedures except when sterilization was originally caused by
trauma). Uninsured hospital services also include: preferred
accommo­dation at the patient’s request; preferred medical/
surgical supplies; 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).
In 2012–2013, the Medicare Protection Act and the Medical
and Health Care Services Regulation were amended to permit
British Columbians to be absent from the province for seven
months in a year, an increase from six months, for vacation
purposes.
Services not insured under the 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.
to be a resident, but does not include a tourist or visitor
to British Columbia.
Section 1 of the MPA, defines a resident as a person who:
• is a citizen of Canada or is lawfully admitted to Canada
for permanent residence;
• makes his or her home in British Columbia, and
• is physically present in British Columbia for at least six
months in a calendar year, or for a prescribed shorter
period of time, and
• includes a person who is deemed under the regulations
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.
The Medicare Protection Act (section 45) prohibits the sale
or issuance of health insurance by private insurers to patients
for services that would be benefits if performed by a practitioner. 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.”
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 of arrival 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.
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 the BCMA’s
Tariff Committee. In 2012–2013, three fee items from the
Section of Cardiac Surgery were removed from the Fee
Schedule; two of the fee items were for procedures which
are now obsolete and one fee item was redundant.
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.
3.0UNIVERSALITY
3.1 Eligibility
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 health care benefits.
Canada Health Act — Annual Report 2012–2013
The number of residents registered with MSP as of
March 31, 2013, was 4,594,940.
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 Medicare Protection Act and section 2
of the Medical and Health Care Services Regulation.
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Chapter 3: British Columbia
3.3 Premiums
The enabling legislation is:
• Medicare Protection Act (British Columbia), Part 2 —
Beneficiaries section 8; and
• Medical and Health Care Services Regulation (British
Columbia) Part 3 — Premiums.
Enrolment in MSP is mandatory and payment of premiums
is ordinarily a requirement for coverage. However, failure
to pay premiums is not a barrier to coverage for those
who meet the basic enrolment eligibility criteria. Monthly
premiums for MSP since January 1, 2013, are $66.50 for
one person, $120.50 for a family of two, and $133.00 for
a family of three or more.
MSP has two programs that offer assistance with the
payment of premiums based on financial need. Regular
premium assistance has five levels of assistance and is
based on a person’s net income for the preceding tax year,
combined with that of the person’s spouse if applicable,
less MSP deductions. 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.
4.0 PORTABILITY
4.1 Minimum Waiting Period
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,
because in 2012–2013, the Medical and Health Care
Services Regulation was amended to permit residents of
British Columbia to be absent from the province for up
to seven months in a 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 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 interprovincial and interterritorial reciprocal
billing arrangements, physicians, except in Quebec, bill their
own medical plans directly for services rendered to eligible
Medical Services Plan (MSP) British Columbia residents,
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 out-patient services, the payment is at the
interprovincial and interterritorial reciprocal billing rate.
Payment for these services, except for excluded services that
are billed to the patient, is handled though interprovincial
and interterritorial reciprocal billing procedures.
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.
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.
4.2 Coverage During Temporary Absences in Canada
4.3 Coverage During Temporary Absences
Outside Canada
Sections 3, 4 and 5 of the Medical and Health Care Services
Regulation of the Medicare Protection Act 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
108
British Columbia pays host provincial rates for insured
services according to rates established by the Interprovincial
Health Insurance Agreements Coordinating Committee.
The enabling legislation that defines portability of health
insurance during temporary absences outside Canada
is stated in the Hospital Insurance Act, section 24; the
Hospital Insurance Act Regulations, Division 6; the
Medicare Protection Act, section 51; and the Medical
and Health Care Service Regulation, sections 3, 4, 5.
Canada Health Act — Annual Report 2012–2013
Chapter 3: British Columbia
Residents who leave British Columbia temporarily to attend
school or university may be eligible for MSP coverage for
the duration of their studies, provided they were physically
present in Canada for 6 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, longer term vacationers who are
deemed residents may qualify for a total absence of up to
seven months per calendar year, because in 2012–2013, the
Medical and Health Care Services Regulation was amended
to permit residents of British Columbia to be absent from
the province for up to seven months in a 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 twelve 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.
4.4 Prior Approval Requirement
No prior approval is required for medically required
procedures that are covered under the interprovincial
reciprocal agreements with other provinces. Prior
approval from the MSC is required for procedures
that are excluded under the reciprocal agreements.
Canada Health Act — Annual Report 2012–2013
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 (TENS),
moxibustion, biofeedback, hypnotherapy; services to persons
covered by other agencies (e.g. Canadian Armed Forces,
Workers’ Compensation Board, Department of Veterans
Affairs, Correctional Services of Canada); services requested
by a “third party”; team conference(s); genetic screening
and other genetic investigation, including DNA probes;
procedures still in the experimental/developmental phase;
and anaesthetic services and surgical assistant services
associated with all of the foregoing.
The services on this list may or may not be reimbursed
by the home province. The patient should make inquiries
of that home province after direct payment to the British
Columbia physician. Some treatments (e.g., treatment
services in not-for-profit residential facilities) may require
the recommendation of the Ministry of Health.
All non-emergency procedures performed outside Canada
require approval from the MSC before the procedure.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
Beneficiaries in British Columbia, as defined in section 1
of the Medicare Protection Act, are eligible for all insured
hospital and medical care services as required. To ensure
equal access to all, regardless of income, the Medicare
Protection Act, sections 17 and 18, prohibits extra-billing
by enrolled practitioners.
Access to Insured Services
Access to insured services continues to be enhanced:
• In 2012–2013, approximately 3,000 general practitio-
ners (GPs) and specialists received all or part of their
income through British Columbia’s Alternative Payments
Program, which funds regional health authorities to
contract with or hire physicians, in order to deliver
insured clinical services.
• The Full-Service Family Practice Incentive Program
continues to be expanded as the Ministry of Health
(the Ministry) and physicians continue to work together
to develop incentives aimed at helping to support and
sustain full service family practice.
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Chapter 3: British Columbia
• The Ministry provides funding through the Medical
• Rural Continuing Medical Education — offers
• The Ministry continued and implemented several
• Recruitment Incentive Fund — provides an incen-
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 health care services to unassigned
patients in a reliable, effective, and efficient manner.
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:
• Rural Retention Program — provides eligible
physicians (estimated at 1,800) with fee premiums.
It 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.
• Northern and Isolation Travel Assistance Outreach
Program — provides funding support for approved
physicians who visit rural and isolated communities
to provide medical service(s).
• Rural 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 also
provided vacation relief.
• Rural Specialist Locum Program — assists rural spe-
cialists in taking vacations and continuing medical
education by providing paid locum support. The
program provided locum support for core specialists
in 18 rural communities to provide vacation relief
and assistance while physician recruitment efforts
were underway.
• Rural Emergency Enhancement Fund — provides
funding to support eligible rural communities for
physician groups that commit to work as a team to
maintain public access to emergency department
services in rural hospitals.
• Rural 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.
110
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.
tive to physicians to fill vacancies that are part of the
Physician Supply Plan in eligible rural communities.
• Rural 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.
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 at hospitals in locations including
Surrey, Vancouver, Vernon, Kelowna, Courtenay/Comox,
and Campbell River, 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, the British Columbia Medical Association
(BCMA), 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 the BCMA.
Its Subsidiary Agreements and Appendices provide
additional detail related to:
• Physician benefits (the Benefits Subsidiary Agreement) —
outlines programs that provide contractually negotiated
benefits.
Canada Health Act — Annual Report 2012–2013
Chapter 3: British Columbia
• Rural programs (the Rural Practice Subsidiary Agreement)
— provides financial incentives for physicians to establish
their practice in rural and remote communities.
• Alternative Payment Programs (The Alternative Payments
Subsidiary Agreement) — outlines the specific terms and
conditions applicable to alternative payment agreements.
• Programs specific to GPs (General Practitioner
Subsidiary Agreement) and Specialists (Specialist
Subsidiary Agreement) — establishes the General
Practitioners Services Committee, the Specialist
Services Committee, and the Shared Care Committee.
• Appendix G — Medical On-Call/Availability Program
(MOCAP) provides payments to physicians and physician groups who provide coverage for patients, other
than their own or their call groups, which includes
funding for Doctor of the Day payments. This provides
greater flexibility for health authorities in purchasing
MOCAP coverage and Doctor of the Day services.
• Appendix J — Laboratory Medicine Fee Agreement
establishes targets for the total annual outpatient
laboratory expenditures and agreed to the formation
of the Laboratory Reform Committee.
The PMA gives the BCMA 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 the BCMA
through various joint committees. It also provides 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 health care services are reinforced in the PMA.
The PMA establishes the compensation and benefit structure
for physicians who provide publicly funded medical services
whether on fee-for-service or alternate funding methods
(service contracts, salaries, and sessional arrangements).
Through the PMA, the province also provides targeted
financial support for such areas as: rural physician incentive programs; access to specialist services; supporting full
service family practices; and shared care models involving
GPs, specialists, and other healthcare professions.
Physicians are licensed under the Health Professions Act
with their Payment Schedule established under section 26
of the Medicare Protection Act. The agreement provides processes for monitoring and managing the funding established
by the MSC for allocation under section 25 of the Medicare
Protection Act 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.
Canada Health Act — Annual Report 2012–2013
Dentists are licensed under the Health Professions Act.
The province and the British Columbia Dental Association
(BCDA) negotiated a Memorandum of Understanding that
is effective from April 1, 2012 to March 31, 2014 and
covers the following services: dental surgery; oral surgery;
orthodontic services; oral medicine; and dental technical
procedures. Both the province and the BCDA agree to 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 the MSP to individual physicians,
based on submitted claims, and through the Alternative
Payment Program to health authorities for physicians’
services. In 2012–2013, approximately 72 percent of
medical expenditures were distributed as fee-for-service
and 11 percent were distributed as alternative payments.
Of the alternative payments, approximately 79.5 percent
were distributed through contracts, 19 percent as sessions
(3.5-hour units of service), and 1.5 percent as salaried
arrangements. The government funds health authorities
for alternative payments; it does not pay physicians directly.
In British Columbia, for dentistry services, 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
Funding for hospital services is included in the annual
funding allocation and payments made to health authorities. This funding allocation is to be 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. 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 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 health care services.
The Ministry of Health does not specifically fund hospitals
directly — instead health authorities are funded and provide
operating budgets to hospitals within their control to deliver
specified services. There is an exception to this wherein
funding targeted for specific priority projects (e.g., reduction in wait times for hips and knees, and patient-focused
funding) is provided to health authorities (again not directly
to hospitals) and since it is specifically earmarked, it must
be reported on separately.
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Chapter 3: British Columbia
The Ministry of Health introduced patient-focused
funding in 2010–2011 under which a portion of eligible
acute care funding was based on actual workload performed. The Ministry continued the Patient-Focused
Funding (PFF) initiative in 2011–2012 and 2012–2013,
and health authorities participated in PFF initiatives,
such as Emergency Department Pay-for-Performance;
Procedural Care Programs (e.g., Magnetic Resonance
Imaging); Community Programs; Activity Based Funding;
and National Surgical Quality Improvement). The Ministry
continues to examine alternative funding methodologies
including the use of pay-for-performance and activitybased 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 2012–2013,
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 province-wide programs).
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.
6.0 RECOGNITION GIVEN TO
FEDERAL TRANSFERS
Insured hospital services are included within the annual
funding allocations to health authorities, as well as specifically targeted funding from time to time. 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 the payments to physicians and payments for prescription
drugs covered under PharmaCare.
• Estimates, Fiscal Year Ending March 31, 2013,
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
2012–2013, these documents included:
available at: www.bcbudget.gov.bc.ca/2012/
estimates/2012_Estimates.pdf
• Budget and Fiscal Plan 2012–2013 and 2014–2015,
which includes the 2012–2013 Third Quarterly Report,
available at: www.bcbudget.gov.bc.ca/2012/bfp/
2012_Budget_Fiscal_Plan.pdf
• Public Accounts 2012–2013, available at:
www.fin.gov.bc.ca/ocg/pa/12_13/Pa12_13.htm
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Canada Health Act — Annual Report 2012–2013
Chapter 3: British Columbia
Registered Persons
1. Number as of March 31st (#).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
4,402,540
4,469,177
4,521,503
4,565,864
4,594,940
Insured Hospital Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
119
119
119
120
120
not available
not available
not available
not available
not available
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
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 ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
7,102
6,846
5,909
6,551
6,886
64,550,692
64,655,739
67,078,612
69,785,313
68,904,638
95,326
87,948
78,075
86,544
97,088
24,262,195
24,188,890
21,830,298
25,327,347
28,643,797
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
1,963
3,056
2,469
2,961
4,091
11,811,654
6,058,867
4,452,628
4,152,060
4,520,778
1,630
1,920
1,940
2,468
2,915
967,704
1,174,112
999,733
1,301,179
1,646,810
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: $7.1 billion in
2006–2007, $7.6 billion in 2007–2008, $8.2 billion in 2008–2009, $8.6 billion in 2009–2010, $9.2 billion in 2010–2011, $9.7 billion in 2011–2012,
and $10.1 billion in 2012–2013. Canada Health Act — Annual Report 2012–2013
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Chapter 3: British Columbia
Insured Physician Services Within Own Province or Territory
2008–2009
14.Number of participating physicians (#).
8,986
2009–2010
3
9,201
2010–2011
3
9,417
2011–2012
9,628
3
2012–2013
9,947
3
15.Number of opted-out physicians (#).
5
5
5
5
4
16.Number of non-participating physicians (#).
2
2
not available
not available
not available
not available
not available
not available
not available
not available
2,334,513,866
2,460,943,779
2,541,874,909
2,619,943,719
2,656,938,267
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
735,928
622,277
625,981
653,387
628,705
28,686,013
29,560,007
30,698,752
32,453,109
32,502,933
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
82,628
75,910
82,247
91,026
83,050
4,524,790
4,013,791
4,240,090
4,869,497
4,340,034
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
249
243
236
218
217
46,736
50,341
51,036
52,047
50,813
7,289,302
8,093,266
7,991,262
8,130,009
7,903,742
3. The number of participating physicians in item 14 is for physicians who received payments through fee-for-service.
114
Canada Health Act — Annual Report 2012–2013
3
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
Yukon
Introduction
The health care insurance plans operated by the Government
of Yukon are the Yukon Health Care Insurance Plan (YHCIP)
and the Yukon Hospital Insurance Services Plan (YHISP).
The YHCIP is administered by the Director, as appointed
by the Executive Council Member (Minister of Health
and Social Services). The YHISP is administered by the
Administrator, as appointed by the Commissioner in
Executive Council (Commissioner of the Yukon Territory).
The Director of the YHCIP and the Administrator of the
YHISP are hereafter referred to as the Director, Insured
Health and Hearing Services. References in this text to the
“Plan” refer to either the Yukon Health Care Insurance
Plan or the Yukon Hospital Insurance Services Plan.
The objective of the Yukon Health Care System 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. The Minister, Health and Social
Services, is responsible for delivering all insured health
care services. Service delivery is administered centrally
by the Department of Health and Social Services.
Other insured services provided to eligible Yukon residents include the Children’s Drug and Optical Program;
the Chronic Disease and Disability Benefits Program; the
Pharmacare and Extended Benefits Programs; and the
Travel for Medical Treatment Program. Non-insured health
service programs include Community Health; Community
Nursing; Continuing Care; and Mental Health Services.
In November 2012, the Yukon government approved the
Yukon Registered Nurses Association’s Registered Nurses
Profession Regulation. This regulation introduced the scope
of practice for nurse practitioners (NPs) and enabled Yukon
to license the profession. Licensing NPs to work in Yukon
will increase the number of highly trained health care professionals available to Yukoners. The inclusion of NPs as a class
of registered nurses expands health care options for patients,
provides cost saving opportunities in the health care system
and enhances the recruitment and retention of nurses. Yukon
currently has one NP working in its continuing care branch.
Canada Health Act — Annual Report 2012–2013
The Yukon Hospital Corporation constructed two new
medical facilities — one in Dawson City (scheduled to open
at the end of 2013) and the other in Watson Lake which
became operational September 2013.
The Yukon government continues to utilize modern technology to improve health care services for Yukoners. It has
invested in tele-radiology to provide computer radiology
in 13 Community Health Centres across the territory, and
has expanded the Tele-health video conferencing equipment
capabilities within the First Nations health offices.
The Department of Health and Social Services continues
to successfully administer the Yukon Weight Wise program.
The program provides tertiary medical, psychological, and
surgical interventions and supports individuals with obesity
who require complex medical management and/or surgical
intervention. The goal of the program is to assist clients to
achieve healthy weight and lifestyle habits to reduce medical complications for the client and potential costs to the
healthcare system. In 2012, psychology services were added
to support clients as they navigate the weight wise program.
2011–2012 saw 96 individuals access the program for a
total weight loss of 3,779 pounds.
The Referred Care Clinic (RCC) was established in
December 2011 with a goal to provide comprehensive,
integrated health services to “unattached patients” with
complex care needs (individuals who have concurrent
addictions, pain management or mental health challenges)
many of whom frequently present at the Whitehorse
General Hospital Emergency Room. In 2013, the Department
of Health and Social Services received approval to extend
and expand the RCC to full time operations for a three
year period which will allow the department and RCC
operators to implement a full program evaluation.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and Public Authority
The Health Care Insurance Plan Act, section 3(2) and
section 4, establishes the public authority to operate the
health medical care plan. There were no amendments
made to these sections of the Act in 2012–2013.
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Chapter 3: Yukon
The Hospital Insurance Services Act, section 3(1) and
section 5, establishes the public authority to operate the
health hospital care plan. There were no amendments
made to these sections of the Act in 2012–2013.
• appoint inspectors and auditors to examine and obtain
Subject to the Health Care Insurance Plan Act (section 5)
and regulations, the mandate and function of the Director,
Insured Health and Hearing Services, is to:
• perform any other functions and discharge any other
• administer the Plan;
• determine eligibility for entitlement to insured
1.2 Reporting Relationship
health services;
• register persons in the Plan;
• make payments under the Plan, including the
determination of eligibility and amounts;
• determine the amounts payable for insured health
services outside the Yukon;
• establish advisory committees and appoint individuals
to advise or assist in the operation of the Plan;
• conduct actions and negotiate settlements in the exercise
of the Government of Yukon’s right of subrogation under
the Act to the rights of insured persons;
• conduct surveys and research programs and obtain
statistics for such purposes;
• establish what information is required to be provided
under the Act and the form that information must take;
• appoint inspectors and auditors to examine and
obtain information from medical records, reports,
and accounts; and
• perform any other functions and discharge any other
duties assigned by the Minister of Health and Social
Services under the Act.
Subject to the Hospital Insurance Services Act (section 6)
and the regulations, the mandate and function of the
Director, Insured Health and Hearing Services, is to:
• develop and administer the hospital insurance plan;
• determine eligibility for and entitlement to insured
services;
• determine the amounts that may be paid for the cost
of insured services provided to insured persons;
• 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;
• approve hospitals for the purposes of the Act;
• conduct surveys and research programs and obtain
information from hospital records, reports, and accounts;
• prescribe the forms and records necessary to carry out
the provisions of the Act; and
duties assigned to the administrator by the Regulations.
The Department of Health and Social Services is accountable
to the Legislative Assembly and the Government of Yukon
through the Minister.
Section 6 of the Health Care Insurance Plan Act and
section 7 of the Hospital Insurance Services Act require
that the Director, Insured Health and Hearing Services,
make an annual report to the Minister of Health and Social
Services respecting the administration of the two health
insurance plans. A Statement of Revenue and Expenditures
is tabled in the legislature and is subject to discussion at that
level. The Health and Social Services Council Annual Report
was released for fiscal year 2011–2012. The 2012–2013
Annual Report will be provided in the fall of 2013.
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. It focused on the
Department’s planning processes and the way it manages
its health programs and services, focusing on diabetes and
alcohol and drug services programs.
Regarding the Yukon Hospital Corporation, section 13(2) of
the Hospital Act requires the Corporation to submit a report
of their operations for that fiscal year to the Minister within
6 months after the end of each financial year. The report is
to include the financial statements of the Corporation and
the auditor’s report.
statistics for those purposes;
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Canada Health Act — Annual Report 2012–2013
Chapter 3: Yukon
2.0 COMPREHENSIVENESS
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. There were no amendments made to
these sections of the legislation in 2012–2013.
In 2012–2013, insured in-patient and out-patient hospital
services were delivered in 15 facilities throughout the territory. These facilities include one general hospital, one
hospital and 13 health centres. 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.
Currently, the Yukon Hospital Corporation operates
under a three-year accreditation through Accreditation
Canada. Whitehorse General Hospital successfully received
accreditation until 2014. In addition, the Yukon Hospital
Corporation assumed responsibility for Watson Lake
Hospital which also successfully completed the accreditation
primer for 2012.
The Yukon government assumed responsibility for operating
health centres from the federal government in April 1997.
These facilities, including the Watson Lake Cottage Hospital,
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.
Pursuant to the Hospital Insurance Services Regulations,
section 2(e) and (f), services provided in an approved hospital
are insured. Section 2(e) defines in-patient insured services as
all of the following services to in-patients, namely: accommodation and meals at the standard or public ward level;
necessary nursing service; laboratory, radiological and other
diagnostic procedures together with the necessary interpretations for the purpose of maintaining health, preventing
disease and assisting in the diagnosis and treatment of an
injury, illness or disability; drugs, biologicals and related
preparations as provided in Schedule B of the regulations,
when administered in the hospital; use of operating room,
case room and anaesthetic facilities, including necessary
Canada Health Act — Annual Report 2012–2013
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 therefore 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
therefore 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.
These measures will help reduce Yukon’s reliance on out-ofterritory services.
2.2 Insured Physician Services
Sections 1 to 8 of the Health Care Insurance Plan Act and
sections 2, 3, 7, 10 and 13 of the Health Care Insurance
Plan Regulations provide for insured physician services.
There were no amendments made to these sections of the
legislation in 2012–2013.
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:
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Chapter 3: Yukon
• 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 2012–2013 was
70 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
a fee for services rendered. Notice in writing of this election
must be submitted to the Director, Insured Health and
Hearing Services. In 2012–2013, there were physicians both
on fee-for-service and alternate payment arrangements for
remuneration.
Insured physician services in Yukon are defined as medically
required services rendered by a medical practitioner.
The process used to add a new fee to the Payment Schedule
for Yukon is administered through a committee structure.
This process requires physicians to submit requests in writing
to the Yukon Health Care Insurance Plan/Yukon Medical
Association Liaison Committee.
Following review by this committee, a decision is made to
include or exclude the service. The relevant costs or fees
are normally set in accordance with similar costs or fees in
other jurisdictions. Once a fee-for-service value has been
determined, notification of the service and the applicable
fee is provided to all Yukon physicians. Public consultation
is not required.
Alternatively, new fees can be implemented as a result of
the fee negotiation process between the Yukon Medical
Association and the Department of Health and Social
Services. The Director, Insured Health and Hearing Services,
manages this process and no public consultation is required.
2.3 Insured Surgical-Dental Services
Dentists providing insured surgical-dental services under
the health care insurance plan of Yukon must be licensed
pursuant to the Dental Professions Act and are given billing
numbers to bill the Yukon Health Care Insurance Plan for
providing insured dental services. The Plan is also billed
directly for services provided outside the territory.
Insured dental services are limited to those surgical-dental
procedures listed in Schedule B of the Health Care Insurance
Plan Regulations. The procedures must be performed in
a hospital.
The addition or deletion of new surgical-dental services to
the list of insured services requires amendment by Orderin-Council to Schedule B of the Health Care Insurance Plan
118
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.
There were no new insured surgical-dental services added
in 2012–2013.
2.4 Uninsured 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/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.
Uninsured dental services include procedures considered
restorative and procedures that are not performed in a hospital under general anaesthesia.
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 noninsured services, such as fibreglass casts, does not delay or
prevent access to insured services at any time. Insured persons are given treatment options at the time of service.
Yukon has no formal process to monitor compliance;
however, feedback from physicians, hospital administrators, medical professionals and staff allows the Director of
Insured Health and Hearing Services to monitor usage and
service concerns.
Physicians in Yukon may bill patients directly for noninsured services. Block fees are not used at this time;
Canada Health Act — Annual Report 2012–2013
Chapter 3: Yukon
however, some do bill by service item. Billable services
include but are not limited to: completion of employment
forms; medical-legal reports; transferring records; thirdparty examinations; some elective services; and telephone
prescriptions, advice or counseling. Payment does not affect
patient access to services because not all physicians or clinics
bill for these services and other agencies or employers may
cover the cost.
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 2012–2013.
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,
2013, no insured in-patient or out-patient hospital services,
as provided for in the regulations, have been de-insured.
The Director, Insured Health and Hearing Services, is
responsible for managing this process in conjunction with
the Yukon Hospital Corporation.
Surgical-dental services — an amendment by Order-InCouncil to Schedule B of the Health Care Insurance Plan
Regulations is required. A service could be de-insured if
determined not medically necessary or is no longer required
to be carried out in a hospital under general anaesthesia.
The Director, Insured Health and Hearing Services, manages
this process. No surgical-dental services were de-insured in
2012–2013.
3.0UNIVERSALITY
3.1 Eligibility
Eligibility requirements for insured health services are set
out in the Health Care Insurance Plan Act and regulations,
sections 2 and 4 respectively, and the Hospital Insurance
Services Act and regulations, sections 2 and 4 respectively.
No changes were made to these sections of the legislation
in 2012–2013. 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
Canada Health Act — Annual Report 2012–2013
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, 2013 was 37,048.
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.
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Chapter 3: Yukon
4.0 PORTABILITY
4.1 Minimum Waiting Period
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.
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.
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.
4.2 Coverage During Temporary Absences in Canada
Insured services provided to Yukon residents while
temporarily absent from the territory, are paid at the
rates established by the host province.
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 is entitled to
insured services during a period of 12 months continuous
absence.” Persons leaving Yukon for a period exceeding three
months are advised to contact Yukon Insured Health Services
and complete a Temporary Absence form. Failure to do so
may result in cancellation of coverage.
Students attending educational institutions full-time outside
Yukon remain eligible for the duration of their academic
studies. The Director of 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.
No amendments were made to these sections of the
legislation in 2012–2013.
Yukon participates fully with the Inter-Provincial 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
120
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.
4.3 Coverage During Temporary Absences
Outside Canada
The provisions that define portability of health care insurance to insured persons during temporary absences outside
Canada are defined in sections 5, 6, 7, 9, 10 and 11 of
the Yukon Health Care Insurance Plan Regulations and
sections 6, 7(1), 7(2) and 9 of the Yukon Hospital Insurance
Services Regulations.
No amendments were made to these sections of the legislation in 2012–2013. Sections 5 and 6 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.”
Persons leaving Yukon for a period exceeding three months
are advised to contact Yukon Health Care Insurance Plan
and complete a Temporary Absence form. Failure to do so
may result in cancellation of the coverage.
The provisions for portability of health insurance during
out-of-country absences for students, temporary workers
and missionaries are the same as for absences within Canada
(see section 4.2 of this report).
Insured physician services provided to eligible Yukon
residents temporarily outside the country are paid at rates
equivalent to those paid had the service been provided in
Yukon. Reimbursement is made to the insured person by
the Yukon Health Care Insurance Plan or directly to the
provider of the insured service.
Insured in-patient hospital services provided to eligible
Yukon residents outside Canada are paid at the rate
established in the Standard Ward Rates Regulation for
the Whitehorse General Hospital.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Yukon
Insured out-patient hospital services provided to eligible Yukon
residents outside Canada are paid at the rate established in
the Charges for Out-Patient Procedures Regulation.
4.4 Prior Approval Requirement
There is no legislated requirement that eligible residents
must seek prior approval before seeking elective or emergency hospital or physician services outside Yukon or
outside Canada.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
There are no user fees or co-insurance charges under the
Yukon Health Care Insurance Plan or the Yukon Hospital
Insurance Services Plan. All services are provided on a
uniform basis and are not impeded by financial or other
barriers. There is no extra-billing in the 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 2012–2013, a physician Recruitment and Retention
Strategy was developed in collaboration with the Yukon
Medical Association and the Referred Care Clinic funding
was approved for an additional three years. 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.
In the spring of 2013, the hours of the Referred Care
Clinic were also expanded to better meet the needs of
the client base.
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
Canada Health Act — Annual Report 2012–2013
Yukon. The final agreement is signed with the concurrence
of both parties.
The Memorandum of Understanding expired on March 31,
2012. Negotiations were ratified on October 18, 2012,
which now provides for a new 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 2012–2013.
The fee-for-service system is used to reimburse the majority
of physicians providing insured services to residents. Other
systems of reimbursement include contract payments and
sessional payments.
5.3 Payments to Hospitals
The Government of Yukon funds the Yukon Hospital
Corporation (Whitehorse General 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 and Watson Lake are
funded directly through a contribution agreement. When the
hospital in Dawson City becomes operational, it too will be
funded by way of 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 2012–2013.
6.0 RECOGNITION GIVEN TO FEDERAL
TRANSFERS
The Government of Yukon has acknowledged the federal
contributions provided through the Canada Health Transfer
(CHT) in its 2012–2013 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.
121
Chapter 3: Yukon
Registered Persons
1. Number as of March 31st (#).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
33,983
35,084
36,063
36,694
37,048
Insured Hospital Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
15
15
15
15
15
49,051,490
51,734,000
57,655,576
58,943,422
60,949,077
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
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
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($). 3
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
1,013
956
1,047
996
1,173
11,183,888
15,333,983
16,583,657
13,507,016
15,890,700
9,983
12,830
13,197
13,550
14,036
2,888,247
3,248,555
3,413,932
3,974,870
4,425,670
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
13
19
25
20
18
12,003
67,671
45,893
100,716
70,556
40
92
74
77
61
8,233
18,862
12,741
21,950
19,823
1. Public facilities are the 13 health centres (Beaver Creek, Destruction Bay, Carcross, Carmacks, Dawson, Faro, Haines Junction, Mayo, Old Crow,
Pelly Crossing, Ross River, Teslin and Whitehorse) and 2 hospitals (Whitehorse 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, 2012-13 reporting period is
still open until March 31, 2014)
122
Canada Health Act — Annual Report 2012–2013
Chapter 3: Yukon
Insured Physician Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
67
69
69
74
70
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
19,139,117
20,781,850
21,549,640
22,387,839
22,690,228
16,294,365
17,719,117
17,701,880
18,373,627
18,660,715
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 ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
45,744
50,893
54,007
53,915
59,649
2,297,501
3,008,828
3,185,612
3,219,166
3,563,528
Insured Physician Services Provided Outside Canada
21.Number of services (#).
not available
not available
not available
not available
not available
22.Total payments ($).
not available
not available
not available
not available
not available
Insured Surgical-Dental Services Within Own Province or Territory 5
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
4
4
2
3
3
23
4
4
14
26
25,602
6,271
4,631
13,913
21,845
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.
Canada Health Act — Annual Report 2012–2013
123
124
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
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 2012–2013 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 Act will 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.
• Changes were made to the Hospital Insurance
Regulations under the Hospital Insurance and Health
and Social Services Administration Act to establish
a long term care rate that could be adjusted annually for inflation without further amendments to the
Regulations.
• Work began on amending the Medical Care Act to
remove Royal Canadian Mounted Police (RCMP)
from the list of residents not eligible for insured services.
This amendment will reflect 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.”
• Work 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.
Canada Health Act — Annual Report 2012–2013
More information on DHSS legislative initiatives is
available in the Health and Social Services Annual Report,
to be released in the fall of 2013.
1.0 PUBLIC ADMINISTRATION
1.1 Health Care 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. Eligibility
requirements for the Health Care Plan are found in both
the Medical Care Act and the HIHSSA.
1.2 Reporting Relationship
Reporting to the Minister, the Department, the six regional
Health and Social Service Authorities (HSSAs), the Tlicho
Community Services Agency (TCSA) and the Stanton
Territorial Health Authority, plan, manage, deliver and
evaluate a wide spectrum of health and social services at
both the community and facility level throughout the NWT.
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.
Boards of Management established by the Minister 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 and the Minister of the Department
125
Chapter 3: Northwest Territories
of Aboriginal Affairs and Intergovernmental Relations
(DAAIR) will appoint a chairperson after consulting with
the members. Members serve for a maximum of four
years and the chairperson’s term is fixed by the Minister
of DAAIR. Boards of Management manage, control and
operate health and social services facilities within the government’s existing resources, policies and directives; and
are accountable to the Minister. TCSA is deemed a board
of management and provisions of HIHSSA apply except
where there is an inconsistency with the TCSA Act.
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.
2.0 COMPREHENSIVENESS
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 provides an exhaustive list
of services to provide care to its residents.
Insured in-patient hospital services include:
• meals and accommodation at the ward level;
• required nursing services;
• laboratory, diagnostic and imaging services (along with
necessary interpretations);
• drugs, biologicals and other preparations administered
in the hospital;
• surgical supplies and use of operating room;
• case room and anaesthesiology services;
• radiology and rehab therapy (physio, audio, occupational
and speech);
• psychiatric and psychological services within an approved
program; and
• detoxification at approved centers.
126
Insured out-patient hospital services include:
• laboratory tests;
• diagnostic imaging (including interpretations
when needed);
• physiotherapy, speech and language pathology
therapy and occupational therapy;
• minor medical and surgical procedures and related
supplies; and
• psychiatric and psychological services under an
approved hospital program.
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.
The Minister may change, add or delete insured hospital services, and determine whether public consultation will occur.
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, 2013,
there were 294 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
• eye 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.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Northwest Territories
The Minister ultimately determines if services will be added,
altered or deleted from the tariff by:
• establishing a medical care plan that provides insured
services to insured persons by medical practitioners that
will qualify and enable the NWT to receive payments of
contributions from the Government of Canada under
the Canada Health Act; and
• approving the fees and charges itemized in the tariff that
may be paid in respect to insured services rendered by
medical practitioners in the NWT and the conditions
under which fees and charges are payable.
2.3 Insured Surgical-Dental Services
Licensed oral surgeons may submit claims for insured surgicaldental work in the NWT. The Province of Alberta’s Schedule
of Oral and Maxillofacial Surgery Benefits is used as a guide.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Not all services provided by hospitals, medical practitioners
and dentists are covered under the Health Care Plan. Some
uninsured services include:
•
•
•
•
•
•
•
•
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;
dressings, bandages, drugs and other consumables
used at the medical practitioner’s office;
• eye glasses and other appliances;
• plaster; and
• services carried out by people who usually are not
medical practitioners such as osteopaths, naturopaths
and chiropractors. Physiotherapy, psychiatry and
psychological therapies are not covered if delivered
in a non-approved location.
For NWT residents to receive items and/or services that are
generally considered uninsured under the health care plan,
prior approval is required. A Medical Advisor makes recommendations to the Director of Medical Insurance regarding
the appropriateness of the request.
Canada Health Act — Annual Report 2012–2013
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.
3.0 UNIVERSALITY
3.1 Eligibility
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.
As a result of the federal Jobs, Growth and Long-term
Prosperity Act, the Canada Health Act was amended to
allow members of the Royal Canadian Mounted Police
(RCMP) to be eligible for coverage under provincial and
territorial health plans. NWT is currently updating the
NWT Medical Care Act to ensure members of the RCMP
are no longer excluded from the list of NWT “insured
persons.” This amendment will reflect administrative
practices that have been in place since April 1, 2013, when
the amendment to the Canada Health Act came into force;
and will ensure 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, 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, 2013, there were 42,786 individuals
registered with the NWT Health Care Plan.
No formal provisions exist for clients to opt out of the
NWT Health Care Plan.
127
Chapter 3: Northwest Territories
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.
4.0 PORTABILITY
4.1 Minimum Waiting Period
Waiting periods for persons moving to the NWT are consistent with the Interprovincial Agreement on Eligibility
and Portability. The waiting period ends the first day of the
third month of residency for those moving permanently to
the NWT, or the first day of the thirteenth month for those
whose work term was for one year and has been extended.
Confirmation of extension may be required.
4.2 Coverage 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 postsecondary school are covered as well. The full cost of insured
services is paid for all services received in other 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).
4.3 Coverage During Temporary Absences
Outside Canada
As per section 4(3) of the Medical Care Act and section 11(1)(b)(ii) of the Canada Health Act, the NWT
provides reimbursement for NWT residents who require
128
medically necessary services while temporarily outside
Canada. Individuals are required to pay up front and seek
reimbursement upon their return to the NWT. Services
rendered outside of Canada will not be reimbursed in
excess of amounts payable when the benefit is rendered
in the NWT. Residents temporarily out of Canada may
receive coverage for up to one year; however, prior
approval is required as well as documentation proving
the NWT will be the individual’s permanent residence
upon return.
4.4 Prior Approval Requirement
Prior approval is required for elective services rendered in
other provinces and outside of Canada. All services from
private facilities require prior approval as well.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
The Medical Travel Program 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 2012–2013, a partnership with Dalhousie University was established to provide 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.
Partnering with the Tlicho Community Services Agency,
19 Personal Support Workers (PSW) were trained this year.
The PSWs increased regional capacity to provide homecare
services to clients in their home for as long as possible.
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.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Northwest Territories
5.2 Physician Compensation
The NWT Medical Association and the Department
negotiate physician compensation. Generally, family
practitioners are compensated through contractual
agreements with the Government of NWT, while the
remainder is compensated on a fee-for-service basis
as determined under 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), Stanton
Territorial Health Authority and the Tlicho Community
Services Agency dictate payments made to hospitals.
Government budgets, resources and levels of services
offered determine the allocated amounts.
Payments to HSSAs providing insured hospital services
are governed under the Hospital Insurance and Health
and Social Services Administration Act and the Financial
Administration Act. A comprehensive budget is used to
fund hospitals in the NWT.
Canada Health Act — Annual Report 2012–2013
6.0 RECOGNITION 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:
•
•
•
•
2012–2013 Budget Address;
2012–2013 Main Estimates;
2012–2013 Public Accounts;
2012–2013 Business Plan for the Department of
Health and Social Services;
• 2012–2013 Business Plan for the Department of
Finance; and
• 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. 2012–2013 estimates
are based on total active physicians for the fiscal year.
129
Chapter 3: Northwest Territories
Registered Persons
1. Number as of March 31st (#).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
46,699
47,544
43,639
44,216
42,786
Insured Hospital Services Within Own Province or Territory
Public Facilities1
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#).
5. Payments to private for-profit facilities
for insured health services ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
27
27
27
27
27
74,256,407
74,628,142
69,613,271
83,425,969
72,850,737
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
1,174
1,104
1,102
1,109
1,212
13,157,987
12,312,420
14,797,822
15,391,596
15,042,181
12,355
11,588
10,607
11,627
11,740
3,574,665
3,473,391
3,525,604
4,073,753
3,984,734
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
11
8
7
12
16
24,078
33,175
54,896
38,898
123,083
39
44
53
44
61
13,642
13,774
31,185
21,484
36,445
All data are subject to future revisions.
130
Canada Health Act — Annual Report 2012–2013
Chapter 3: Northwest Territories
Insured Physician Services Within Own Province or Territory
2008–2009
14.Number of participating physicians (#).
276
2009–2010
1
282
2010–2011
1
290
2011–2012
284
1
2012–2013
1
294
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
35,751,371
37,467,763
39,063,305
39,502,091
41,243,631
1,929,988
1,872,293
1,700,075
1,634,967
1,654,224
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
1
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
46,388
34,265
36,726
42,815
45,677
4,219,209
4,096,290
4,939,640
4,574,911
5,092,545
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
46,388
34,265
36,726
42,815
45,677
4,219,209
4,096,290
4,939,640
4,574,911
5,092,545
Insured Surgical-Dental Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
23.Number of participating dentists (#).
not available
not available
not available
not available
not available
24.Number of services provided (#).
not available
not available
not available
not available
not available
25.Total payments ($).
not available
not available
not available
not available
not available
All data are subject to future revisions.
1. Estimate based on total active physicians for each fiscal year.
Canada Health Act — Annual Report 2012–2013
131
132
Canada Health Act — Annual Report 2012–2013
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2012–2013
Nunavut
Introduction
1.0 PUBLIC ADMINISTRATION
The Department of Health and Social Services faces many
unique challenges when providing for the health and
well-being of Nunavummiut. The population of 31,9061 is
approximately 84 percent Inuit, and almost 61 percent of
the population is under the age of 25 years (19,485 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.
1.1 Health Care Insurance Plan and Public Authority
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, and community
health nurses.
In 2012–2013, the territorial operations and maintenance
budget for the Department of Health and Social Services was
$344,782,000, including supplementary appropriations.3
Just under 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 2012–2013 an additional $10,536,000 was allocated
to the Department for capital projects.4 The Department
of Health and Social Services 2012–2013 capital projects
included: opening a new Community Health Centre, commencing the second phase of renovations to the Qikiqtani
General Hospital (QGH), and undertaking renovations
to repurpose a boarding home into a mental health
transition facility.
To enhance delivery of health services, social programs
were transferred to a new Department of Family Services
on April 1, 2013.
The health care insurance plans of Nunavut, including
physician and hospital services, are administered by
the Department of Health and Social Services 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 and social services 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 and social
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
1. Statistics Canada, 2012 http://www12.statcan.ca/census-recensement/index-eng.cfm (2011 Statistics Canada Census as of October 24, 2012)
2. Statistics Canada, 2012 http://www12.statcan.ca/census-recensement/index-eng.cfm (2011 Statistics Canada Census as of October 24, 2012)
3. Government of Nunavut Supplementary Appropriations for the year ended March 31, 2013
4. Government of Nunavut Capital Estimates for the year ended March 31, 2013
Canada Health Act — Annual Report 2012–2013
133
Chapter 3: Nunavut
Act requires the Minister responsible for the Act to appoint
a Director of Medical 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 Medical Care Plan (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 December 7, 2012.
2.0 COMPREHENSIVENESS
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
2012–2013.
In 2012–2013 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, Cambridge Bay and Iqaluit.
Other community health centres provide public health
services, out-patient services and urgent treatment services.
134
The Department also operates a Family Practice Clinic in
Iqaluit. 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 and social
services 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 and
psychology 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 2012–2013 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 2012–2013. The Nursing Act allows
for licensure of nurse practitioners in Nunavut; this permits
nurses to deliver insured physician 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 main referral centres
in Ottawa, Winnipeg, and Yellowknife. Recruitment of
Canada Health Act — Annual Report 2012–2013
Chapter 3: Nunavut
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.
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 2012–2013.
There are a total of 26 full-time family physician positions in
Nunavut (16 in the Baffin region; 7.5 positions in the Kivalliq
region; 2.5 positions 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 2012–2013, no physicians provided written
notice of this election.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
All physicians practicing in Nunavut are under contract with
the Department.
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-ofterritory 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 2012–2013.
2.3 Insured Surgical-Dental Services
Dentists providing insured surgical-dental services under the
Medical Care Insurance Plan of the territory 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.
Canada Health Act — Annual Report 2012–2013
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 2012–2013 the Qikiqtani General Hospital charged a
$2,205 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.
135
Chapter 3: Nunavut
3.0UNIVERSALITY
3.1 Eligibility
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 2012–2013.
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 was initiated in Nunavut in
2006. 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 the Royal
Canadian Mounted Police (RCMP)5, 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, 2013, 35,0416 individuals were registered
with the Nunavut Health Care Plan, down by 852 from the
previous year. There are no formal provisions for Nunavut
residents to opt out of the Nunavut Health Care Plan.
3.2 Other Categories of Individuals
Non-Canadian holders of employment visas of less
than 12 months, foreign students with visas of less than
12 months, transient workers, and individuals holding
a Minister’s Permit (with the possible exception of those
holding a temporary resident permit who may be reviewed
on a case by case basis) are not eligible for coverage. When
unique circumstances occur, assessments are done on an
individual basis. This is consistent with section 15 of the
Northwest Territories’ Guidelines for Health Care Plan
Registration, which was adopted by Nunavut in 1999.
4.0 PORTABILITY
4.1 Minimum Waiting Period
Consistent with section 3 of the Interprovincial Agreement
on Eligibility and Portability, the waiting period before coverage begins for individuals moving within Canada is three
months, or the first day of the third month following the
establishment of residency in a new province or territory,
or the first day of the third month when an individual, who
has been temporarily absent from his or her home province,
decides to take up permanent residency in Nunavut.
4.2 Coverage During Temporary Absences in Canada
The Medical Care Act, section 4(2), prescribes the benefits
payable where insured medical services are provided outside
Nunavut, but within Canada. The Hospital Insurance and
Health and Social Services Administration Act, sections 5(d)
and 28(1)(j)(o), provide the authority for the Minister to enter
into agreements with other jurisdictions to provide health
services to Nunavut residents and the terms and conditions of
payment. No legislative or regulatory changes were made in
2012–2013 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
5. On June 29, 2012, as a result of the federal Jobs, Growth and Long-term Prosperity Act, the Canada Health Act was amended to allow members of the
RCMP to be eligible for coverage under provincial and territorial health plans. Nunavut amended legislation to allow RCMP to be insured members of the
Nunavut Health Care Plan as of April 1, 2013. This report covers the period of April 1, 2012–March 31, 2013; during this period RCMP were not eligible
for the Nunavut Health Care Plan.
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.
136
Canada Health Act — Annual Report 2012–2013
Chapter 3: Nunavut
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, as of January 1, 2001.
Nunavut participates in physician and hospital reciprocal
billing. As well, special bilateral agreements are in place
with Ontario, Manitoba, Alberta and the Northwest
Territories. The Hospital Reciprocal Billing Agreements
provide payment of in- and out-patient hospital services to
eligible Nunavut residents receiving insured services outside the territory. High-cost procedure rates, newborn rates
and out-patient rates are based on those established by the
Interprovincial Health Insurance Agreements Coordinating
Committee. The Physician Reciprocal Billing Agreements
provide payment of insured physician services on behalf of
eligible Nunavut residents receiving insured services outside
the territory. Payment is made to the host province at the
rates established by that province.
4.3 Coverage During Temporary Absences Outside Canada
The Medical Care Act, section 4(3), prescribes the benefits
payable where insured medical services are provided outside Canada. The Hospital Insurance and Health and Social
Services Administration Act, section 28(1)(j)(o), provides
the authority for the Minister to set the terms and conditions of payment for services provided to Nunavut residents
outside Canada. Individuals are granted coverage for up to
one year if they are temporarily out of the country for any
reason, although they must give prior notice in writing. For
services provided to residents who have been referred out of
the country for highly specialized procedures unavailable in
Nunavut and Canada, Nunavut will pay the full cost. For
non-referred or non-emergency services, the payment for
hospital services is $2,205 per day and for out-patient care
it is $270.
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.
Canada Health Act — Annual Report 2012–2013
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; 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, and electrocardiogram. 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 2012–2013.
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 longterm 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’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 outof-territory regional health authorities and specific facilities
to provide medical specialists and other visiting health
137
Chapter 3: Nunavut
practitioner services. The following specialist services
were provided in Nunavut during 2012–2013 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.
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.
138
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.
6.0 RECOGNITION 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 2012–2013, they included:
• 2012–2013 Budget Address; and
• 2013–2016 Government of Nunavut Business Plan.
Canada Health Act — Annual Report 2012–2013
Chapter 3: Nunavut
Registered Persons
1. Number as of March 31st (#).7
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
32,207
33,540
35,515
35,893
35,041
Insured Hospital Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
28
28
28
28
28
not available
not available
not available
not available
not available
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
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 ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
2,841
2,890
2,924
3,406
3,313
26,481,948
30,013,566
28,527,577
38,486,274
39,244,449
19,579
18,270
18,352
22,725
21,686
6,631,568
5,985,808
6,318,885
8,975,802
7,780,896
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
0
0
0
0
1
11. Total payments, in-patient ($).
0
0
0
0
4,410
12.Total number of claims, out-patient (#).
0
0
0
0
0
13.Total payments, out-patient ($).
0
0
0
0
0
7. The difference in the number of registered Nunavut residents and those covered under the Nunavut Health Care Plan is due to delays in the reconciliation of
data on residents who have left the territory.
Canada Health Act — Annual Report 2012–2013
139
Chapter 3: Nunavut
Insured Physician Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
218
225
225
375
409
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
not available
not available
not available
not available
not available
1,021,829
300,980
312,786
334,539
403,418
14.Number of participating physicians (#).
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).8
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
65,171
72,065
73,564
75,108
80,311
4,768,388
5,585,067
5,901,962
6,393,341
6,341,047
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
36
17
53
22
15
2,458
4,848
1,575
963
732
Insured Surgical-Dental Services Within Own Province or Territory
2008–2009
2009–2010
2010–2011
2011–2012
2012–2013
23.Number of participating dentists (#).
not available
not available
not available
not available
not available
24.Number of services provided (#).
not available
not available
not available
not available
not available
25.Total payments ($).
not available
not available
not available
not available
not available
8. Typically, Nunavut does not pay its physicians through fee-for-service. Instead, the majority of physicians are compensated through contracted salaries.
Statistical information on salaried physicians is reported via the shadow billing process.
140
Canada Health Act — Annual Report 2012–2013
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
Canada Health Act — Annual Report 2012–2013
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.
141
142
Canada Health Act — Annual Report 2012–2013
CANADA
CANADA
CONSOLIDATION
CODIFICATION
Canada Health Act
Loi canadienne sur la
santé
R.S.C., 1985, c. C-6
L.R.C., 1985, ch. C-6
Current to July 8, 2012
À jour au 8 juillet 2012
Last amended on June 29, 2012
Dernière modification le 29 juin 2012
Published by the Minister of Justice at the following address:
http://laws-lois.justice.gc.ca
Publié par le ministre de la Justice à l’adresse suivante :
http://lois-laws.justice.gc.ca
Canada Health Act — Annual Report 2012–2013
143
Published
consolidation is
evidence
Inconsistencies
in Acts
144
OFFICIAL STATUS
OF CONSOLIDATIONS
CARACTÈRE OFFICIEL
DES CODIFICATIONS
Subsections 31(1) and (2) of the Legislation
Revision and Consolidation Act, in force on
June 1, 2009, provide as follows:
Les paragraphes 31(1) et (2) de la Loi sur la
révision et la codification des textes législatifs,
en vigueur le 1er juin 2009, prévoient ce qui
suit :
31. (1) Every copy of a consolidated statute or
consolidated regulation published by the Minister
under this Act in either print or electronic form is evidence of that statute or regulation and of its contents
and every copy purporting to be published by the
Minister is deemed to be so published, unless the
contrary is shown.
31. (1) Tout exemplaire d'une loi codifiée ou d'un
règlement codifié, publié par le ministre en vertu de
la présente loi sur support papier ou sur support électronique, fait foi de cette loi ou de ce règlement et de
son contenu. Tout exemplaire donné comme publié
par le ministre est réputé avoir été ainsi publié, sauf
preuve contraire.
(2) In the event of an inconsistency between a
consolidated statute published by the Minister under
this Act and the original statute or a subsequent
amendment as certified by the Clerk of the Parliaments under the Publication of Statutes Act, the original statute or amendment prevails to the extent of
the inconsistency.
(2) Les dispositions de la loi d'origine avec ses
modifications subséquentes par le greffier des Parlements en vertu de la Loi sur la publication des lois
l'emportent sur les dispositions incompatibles de la
loi codifiée publiée par le ministre en vertu de la présente loi.
NOTE
NOTE
This consolidation is current to July 8, 2012. The last
amendments came into force on June 29, 2012. Any
amendments that were not in force as of July 8, 2012
are set out at the end of this document under the
heading “Amendments Not in Force”.
Cette codification est à jour au 8 juillet 2012. Les
dernières modifications sont entrées en vigueur
le 29 juin 2012. Toutes modifications qui n'étaient
pas en vigueur au 8 juillet 2012 sont énoncées à la
fin de ce document sous le titre « Modifications non
en vigueur ».
Codifications
comme élément
de preuve
Incompatibilité
— lois
Canada Health Act — Annual Report 2012–2013
Preamble
R.S.C., 1985, c. C-6
L.R.C., 1985, ch. C-6
An Act relating to cash contributions by
Canada and relating to criteria and
conditions in respect of insured health
services and extended health care services
Loi concernant les contributions pécuniaires du
Canada ainsi que les principes et
conditions applicables aux services de
santé
assurés
et
aux
services
complémentaires de santé
WHEREAS the Parliament of Canada recognizes:
Considérant que le Parlement du Canada reconnaît :
—that it is not the intention of the Government of Canada that any of the powers,
rights, privileges or authorities vested in
Canada or the provinces under the provisions
of the Constitution Act, 1867, or any amendments thereto, or otherwise, be by reason of
this Act abrogated or derogated from or in
any way impaired;
que le gouvernement du Canada n’entend
pas par la présente loi abroger les pouvoirs,
droits, privilèges ou autorités dévolus au
Canada ou aux provinces sous le régime de
la Loi constitutionnelle de 1867 et de ses modifications ou à tout autre titre, ni leur déroger ou porter atteinte,
—that Canadians, through their system of insured health services, have made outstanding
progress in treating sickness and alleviating
the consequences of disease and disability
among all income groups;
que les Canadiens ont fait des progrès remarquables, grâce à leur système de services de
santé assurés, dans le traitement des maladies
et le soulagement des affections et déficiences parmi toutes les catégories socioéconomiques,
—that Canadians can achieve further improvements in their well-being through combining individual lifestyles that emphasize
fitness, prevention of disease and health promotion with collective action against the social, environmental and occupational causes
of disease, and that they desire a system of
health services that will promote physical
and mental health and protection against disease;
que les Canadiens peuvent encore améliorer
leur bien-être en joignant à un mode de vie
individuel axé sur la condition physique, la
prévention des maladies et la promotion de la
santé, une action collective contre les causes
sociales, environnementales ou industrielles
des maladies et qu’ils désirent un système de
services de santé qui favorise la santé physique et mentale et la protection contre les
maladies,
—that future improvements in health will require the cooperative partnership of governments, health professionals, voluntary organizations and individual Canadians;
que les améliorations futures dans le domaine de la santé nécessiteront la coopération des gouvernements, des professionnels
de la santé, des organismes bénévoles et des
citoyens canadiens,
—that continued access to quality health care
without financial or other barriers will be
critical to maintaining and improving the
health and well-being of Canadians;
Canada Health Act — Annual Report 2012–2013
Préambule
que l’accès continu à des soins de santé de
qualité, sans obstacle financier ou autre, sera
déterminant pour la conservation et l’amélioration de la santé et du bien-être des Canadiens;
1
145
Canada Health — July 8, 2012
Short title
AND WHEREAS the Parliament of Canada
wishes to encourage the development of health
services throughout Canada by assisting the
provinces in meeting the costs thereof;
considérant en outre que le Parlement du
Canada souhaite favoriser le développement
des services de santé dans tout le pays en aidant
les provinces à en supporter le coût,
NOW, THEREFORE, Her Majesty, by and
with the advice and consent of the Senate and
House of Commons of Canada, enacts as follows:
Sa Majesté, sur l’avis et avec le consentement
du Sénat et de la Chambre des communes du
Canada, édicte :
SHORT TITLE
TITRE ABRÉGÉ
1. This Act may be cited as the Canada
Health Act.
1. Loi canadienne sur la santé.
Titre abrégé
1984, ch. 6, art. 1.
1984, c. 6, s. 1.
INTERPRETATION
Definitions
DÉFINITIONS
2. In this Act,
“Act of 1977” [Repealed, 1995, c. 17, s. 34]
“cash
contribution”
« contribution
pécuniaire »
“cash contribution” means the cash contribution in respect of the Canada Health Transfer
that may be provided to a province under sections 24.2 and 24.21 of the Federal-Provincial
Fiscal Arrangements Act;
“dentist” means a person lawfully entitled to
practise dentistry in the place in which the
practice is carried on by that person;
“extended health
care services”
« services
complémentaires
de santé »
“extended health care services” means the following services, as more particularly defined in
the regulations, provided for residents of a
province, namely,
« assuré »
“insured
person”
c) des personnes purgeant une peine d’emprisonnement dans un pénitencier, au sens de
la Partie I de la Loi sur le système correctionnel et la mise en liberté sous condition;
d) des habitants de la province qui s’y
trouvent depuis une période de temps inférieure au délai minimal de résidence ou de
carence d’au plus trois mois imposé aux habitants par la province pour qu’ils soient admissibles ou aient droit aux services de santé
assurés.
(b) adult residential care service,
« contribution » [Abrogée, 1995, ch. 17, art. 34]
(c) home care service, and
(d) ambulatory health care service;
“health care
insurance plan”
« régime
d’assurancesanté »
« assuré » Habitant d’une province, à l’exception :
b) [Abrogé, 2012, ch. 19, art. 377]
(a) nursing home intermediate care service,
“extra-billing”
« surfacturation »
Définitions
a) des membres des Forces canadiennes;
“contribution” [Repealed, 1995, c. 17, s. 34]
“dentist”
« dentiste »
2. Les définitions qui suivent s’appliquent à
la présente loi.
“extra-billing” means the billing for an insured
health service rendered to an insured person by
a medical practitioner or a dentist in an amount
in addition to any amount paid or to be paid for
that service by the health care insurance plan of
a province;
“health care insurance plan” means, in relation
to a province, a plan or plans established by the
law of the province to provide for insured
health services;
146
« contribution pécuniaire » La contribution au
titre du Transfert canadien en matière de santé
qui peut être versée à une province au titre des
articles 24.2 et 24.21 de la Loi sur les arrangements fiscaux entre le gouvernement fédéral et
les provinces.
« contribution
pécuniaire »
“cash
contribution”
« dentiste » Personne légalement autorisée à
exercer la médecine dentaire au lieu où elle se
livre à cet exercice.
« dentiste »
“dentist”
« frais modérateurs » Frais d’un service de santé
assuré autorisés ou permis par un régime provincial d’assurance-santé mais non payables,
« frais
modérateurs »
“user charge”
Canada Health Act — Annual Report 2012–2013
2
Santé — 8 juillet 2012
“health care
practitioner”
« professionnel
de la santé »
“health care practitioner” means a person lawfully entitled under the law of a province to
provide health services in the place in which
the services are provided by that person;
soit directement soit indirectement, au titre
d’un régime provincial d’assurance-santé, à
l’exception des frais imposés par surfacturation.
“hospital”
« hôpital »
“hospital” includes any facility or portion
thereof that provides hospital care, including
acute, rehabilitative or chronic care, but does
not include
« habitant » Personne domiciliée et résidant habituellement dans une province et légalement
autorisée à être ou à rester au Canada, à l’exception d’une personne faisant du tourisme, de
passage ou en visite dans la province.
« habitant »
“resident”
« hôpital » Sont compris parmi les hôpitaux tout
ou partie des établissements où sont fournis des
soins hospitaliers, notamment aux personnes
souffrant de maladie aiguë ou chronique ainsi
qu’en matière de réadaptation, à l’exception :
« hôpital »
“hospital”
(a) a hospital or institution primarily for the
mentally disordered, or
(b) a facility or portion thereof that provides
nursing home intermediate care service or
adult residential care service, or comparable
services for children;
“hospital
services”
« services
hospitaliers »
a) des hôpitaux ou institutions destinés principalement aux personnes souffrant de
troubles mentaux;
“hospital services” means any of the following
services provided to in-patients or out-patients
at a hospital, if the services are medically necessary for the purpose of maintaining health,
preventing disease or diagnosing or treating an
injury, illness or disability, namely,
b) de tout ou partie des établissements où
sont fournis des soins intermédiaires en maison de repos ou des soins en établissement
pour adultes ou des soins comparables pour
les enfants.
(a) accommodation and meals at the standard or public ward level and preferred accommodation if medically required,
« loi de 1977 » [Abrogée, 1995, ch. 17, art. 34]
(b) nursing service,
(c) laboratory, radiological and other diagnostic procedures, together with the necessary interpretations,
(d) drugs, biologicals and related preparations when administered in the hospital,
(e) use of operating room, case room and
anaesthetic facilities, including necessary
equipment and supplies,
(f) medical and surgical equipment and supplies,
(g) use of radiotherapy facilities,
(h) use of physiotherapy facilities, and
(i) services provided by persons who receive
remuneration therefor from the hospital,
« médecin »
“medical
practitioner”
« ministre » Le ministre de la Santé.
« ministre »
“Minister”
« professionnel de la santé » Personne légalement autorisée en vertu de la loi d’une province
à fournir des services de santé au lieu où elle
les fournit.
« professionnel
de la santé »
“health care
practitioner”
« régime d’assurance-santé » Le régime ou les
régimes constitués par la loi d’une province en
vue de la prestation de services de santé assurés.
« régime
d’assurancesanté »
“health care
insurance plan”
« services complémentaires de santé » Les services définis dans les règlements et offerts aux
habitants d’une province, à savoir :
« services
complémentaires
de santé »
“extended health
care services”
a) les soins intermédiaires en maison de repos;
but does not include services that are excluded
by the regulations;
“insured health
services”
« services de
santé assurés »
« médecin » Personne légalement autorisée à
exercer la médecine au lieu où elle se livre à cet
exercice.
b) les soins en établissement pour adultes;
“insured health services” means hospital services, physician services and surgical-dental
services provided to insured persons, but does
not include any health services that a person is
entitled to and eligible for under any other Act
of Parliament or under any Act of the legisla-
c) les soins à domicile;
d) les soins ambulatoires.
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Canada Health Act — Annual Report 2012–2013
3
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.
« services de chirurgie dentaire » Actes de chirurgie dentaire nécessaires sur le plan médical
ou dentaire, accomplis par un dentiste dans un
hôpital, et qui ne peuvent être accomplis convenablement qu’en un tel établissement.
« services de
chirurgie
dentaire »
“surgical-dental
services”
« services de santé assurés » Services hospitaliers, médicaux ou de chirurgie dentaire fournis
aux assurés, à l’exception des services de santé
auxquels une personne a droit ou est admissible
en vertu d’une autre loi fédérale ou d’une loi
provinciale relative aux accidents du travail.
« services de
santé assurés »
“insured health
services”
« services hospitaliers » Services fournis dans
un hôpital aux malades hospitalisés ou externes, si ces services sont médicalement nécessaires pour le maintien de la santé, la prévention des maladies ou le diagnostic ou le
traitement des blessures, maladies ou invalidités, à savoir :
« services
hospitaliers »
“hospital
services”
a) l’hébergement et la fourniture des repas
en salle commune ou, si médicalement nécessaire, en chambre privée ou semi-privée;
b) les services infirmiers;
c) les actes de laboratoires, de radiologie ou
autres actes de diagnostic, ainsi que les interprétations nécessaires;
d) les produits pharmaceutiques, substances
biologiques et préparations connexes administrés à l’hôpital;
e) l’usage des salles d’opération, des salles
d’accouchement et des installations d’anesthésie, ainsi que le matériel et les fournitures
nécessaires;
f) le matériel et les fournitures médicaux et
chirurgicaux;
g) l’usage des installations de radiothérapie;
h) l’usage des installations de physiothérapie;
i) les services fournis par les personnes rémunérées à cet effet par l’hôpital.
R.S., 1985, c. C-6, s. 2; 1992, c. 20, s. 216(F); 1995, c. 17,
s. 34; 1996, c. 8, s. 32; 1999, c. 26, s. 11; 2012, c. 19, ss.
377, 407.
Ne sont pas compris parmi les services hospitaliers les services exclus par les règlements.
148
« services médicaux » Services médicalement
nécessaires fournis par un médecin.
« services
médicaux »
“physician
services”
« surfacturation » Facturation de la prestation à
un assuré par un médecin ou un dentiste d’un
« surfacturation »
“extra-billing”
Canada Health Act — Annual Report 2012–2013
4
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;
Règle générale
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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.
Universalité
1984, ch. 6, art. 10.
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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
Consentement
préalable à la
prestation des
services de santé
assurés
facultatifs
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Definition of
"elective insured
health services"
Accessibility
sured health services provided to a resident of
the province while temporarily absent from the
province if the services in question were available on a substantially similar basis in the
province.
santé assurés facultatifs à un habitant temporairement absent de la province, si ces services y
sont offerts selon des modalités sensiblement
comparables.
(3) For the purpose of subsection (2), “elective insured health services” means insured
health services other than services that are provided in an emergency or in any other circumstance in which medical care is required without delay.
(3) Pour l’application du paragraphe (2),
« services de santé assurés facultatifs » s’entend
des services de santé assurés, à l’exception de
ceux qui sont fournis d’urgence ou dans
d’autres circonstances où des soins médicaux
sont requis sans délai.
1984, c. 6, s. 11.
1984, ch. 6, art. 11.
12. (1) In order to satisfy the criterion respecting accessibility, the health care insurance
plan of a province
12. (1) La condition d’accessibilité suppose
que le régime provincial d’assurance-santé :
Accessibilité
a) offre les services de santé assurés selon
des modalités uniformes et ne fasse pas obstacle, directement ou indirectement, et notamment par facturation aux assurés, à un accès satisfaisant par eux à ces services;
(a) must provide for insured health services
on uniform terms and conditions and on a
basis that does not impede or preclude, either
directly or indirectly whether by charges
made to insured persons or otherwise, reasonable access to those services by insured
persons;
b) prévoie la prise en charge des services de
santé assurés selon un tarif ou autre mode de
paiement autorisé par la loi de la province;
(b) must provide for payment for insured
health services in accordance with a tariff or
system of payment authorized by the law of
the province;
c) prévoie une rémunération raisonnable de
tous les services de santé assurés fournis par
les médecins ou les dentistes;
d) prévoie le versement de montants aux hôpitaux, y compris les hôpitaux que possède
ou gère le Canada, à l’égard du coût des services de santé assurés.
(c) must provide for reasonable compensation for all insured health services rendered
by medical practitioners or dentists; and
(d) must provide for the payment of
amounts to hospitals, including hospitals
owned or operated by Canada, in respect of
the cost of insured health services.
Reasonable
compensation
Définition de
« services de
santé assurés
facultatifs »
(2) In respect of any province in which extra-billing is not permitted, paragraph (1)(c)
shall be deemed to be complied with if the
province has chosen to enter into, and has entered into, an agreement with the medical practitioners and dentists of the province that provides
(2) Pour toute province où la surfacturation
n’est pas permise, il est réputé être satisfait à
l’alinéa (1)c) si la province a choisi de conclure
un accord et a effectivement conclu un accord
avec ses médecins et dentistes prévoyant :
Rémunération
raisonnable
a) la tenue de négociations sur la rémunération des services de santé assurés entre la
province et les organisations provinciales représentant les médecins ou dentistes qui
exercent dans la province;
(a) for negotiations relating to compensation
for insured health services between the
province and provincial organizations that
represent practising medical practitioners or
dentists in the province;
b) le règlement des différends concernant la
rémunération par, au choix des organisations
provinciales compétentes visées à l’alinéa a),
soit la conciliation soit l’arbitrage obligatoire
par un groupe représentant également les or-
(b) for the settlement of disputes relating to
compensation through, at the option of the
appropriate provincial organizations referred
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to in paragraph (a), conciliation or binding
arbitration by a panel that is equally representative of the provincial organizations and
the province and that has an independent
chairman; and
ganisations provinciales et la province et
ayant un président indépendant;
c) l’impossibilité de modifier la décision du
groupe visé à l’alinéa b), sauf par une loi de
la province.
(c) that a decision of a panel referred to in
paragraph (b) may not be altered except by
an Act of the legislature of the province.
1984, ch. 6, art. 12.
1984, c. 6, s. 12.
Conditions
CONDITIONS FOR CASH CONTRIBUTION
CONTRIBUTION PÉCUNIAIRE
ASSUJETTIE À DES CONDITIONS
13. In order that a province may qualify for
a full cash contribution referred to in section 5,
the government of the province
13. Le versement à une province de la pleine
contribution pécuniaire visée à l’article 5 est assujetti à l’obligation pour le gouvernement de
la province :
(a) shall, at the times and in the manner prescribed by the regulations, provide the Minister with such information, of a type prescribed by the regulations, as the Minister
may reasonably require for the purposes of
this Act; and
Referral to
Governor in
Council
a) de communiquer au ministre, selon les
modalités de temps et autres prévues par les
règlements, les renseignements du genre prévu aux règlements, dont celui-ci peut normalement avoir besoin pour l’application de la
présente loi;
(b) shall give recognition to the Canada
Health Transfer in any public documents, or
in any advertising or promotional material,
relating to insured health services and extended health care services in the province.
b) de faire état du Transfert dans tout document public ou toute publicité sur les services de santé assurés et les services complémentaires de santé dans la province.
R.S., 1985, c. C-6, s. 13; 1995, c. 17, s. 37; 2012, c. 19, s.
409(E).
L.R. (1985), ch. C-6, art. 13; 1995, ch. 17, art. 37; 2012, ch.
19, art. 409(A).
DEFAULTS
MANQUEMENTS
14. (1) Subject to subsection (3), where the
Minister, after consultation in accordance with
subsection (2) with the minister responsible for
health care in a province, is of the opinion that
14. (1) Sous réserve du paragraphe (3), dans
le cas où il estime, après avoir consulté conformément au paragraphe (2) son homologue
chargé de la santé dans une province :
(a) the health care insurance plan of the
province does not or has ceased to satisfy
any one of the criteria described in sections 8
to 12, or
a) soit que le régime d’assurance-santé de la
province ne satisfait pas ou plus aux conditions visées aux articles 8 à 12;
Renvoi au
gouverneur en
conseil
b) soit que la province ne s’est pas conformée aux conditions visées à l’article 13,
(b) the province has failed to comply with
any condition set out in section 13,
et que celle-ci ne s’est pas engagée de façon satisfaisante à remédier à la situation dans un délai suffisant, le ministre renvoie l’affaire au
gouverneur en conseil.
and the province has not given an undertaking
satisfactory to the Minister to remedy the default within a period that the Minister considers
reasonable, the Minister shall refer the matter
to the Governor in Council.
Consultation
process
Obligations de la
province
(2) Before referring a matter to the Governor in Council under subsection (1) in respect
of a province, the Minister shall
(2) Avant de renvoyer une affaire au gouverneur en conseil conformément au paragraphe (1) relativement à une province, le ministre :
Étapes de la
consultation
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a) envoie par courrier recommandé à son
homologue chargé de la santé dans la province un avis sur tout problème éventuel;
(a) send by registered mail to the minister
responsible for health care in the province a
notice of concern with respect to any problem foreseen;
b) tente d’obtenir de la province, par discussions bilatérales, tout renseignement additionnel disponible sur le problème et fait rapport à la province dans les quatre-vingt-dix
jours suivant l’envoi de l’avis;
(b) seek any additional information available from the province with respect to the
problem through bilateral discussions, and
make a report to the province within ninety
days after sending the notice of concern; and
c) si la province le lui demande, tient une
réunion dans un délai acceptable afin de discuter du rapport.
(c) if requested by the province, meet within
a reasonable period of time to discuss the report.
Where no
consultation can
be achieved
(3) The Minister may act without consultation under subsection (1) if the Minister is of
the opinion that a sufficient time has expired
after reasonable efforts to achieve consultation
and that consultation will not be achieved.
1984, c. 6, s. 14.
(3) Le ministre peut procéder au renvoi prévu au paragraphe (1) sans consultation préalable s’il conclut à l’impossibilité d’obtenir
cette consultation malgré des efforts sérieux déployés à cette fin au cours d’un délai convenable.
Impossibilité de
consultation
1984, ch. 6, art. 14.
Order reducing
or withholding
contribution
15. (1) Where, on the referral of a matter
under section 14, the Governor in Council is of
the opinion that the health care insurance plan
of a province does not or has ceased to satisfy
any one of the criteria described in sections 8 to
12 or that a province has failed to comply with
any condition set out in section 13, the Governor in Council may, by order,
15. (1) Si l’affaire lui est renvoyée en vertu
de l’article 14 et qu’il estime que le régime
d’assurance-santé de la province ne satisfait pas
ou plus aux conditions visées aux articles 8 à
12 ou que la province ne s’est pas conformée
aux conditions visées à l’article 13, le gouverneur en conseil peut, par décret :
Décret de
réduction ou de
retenue
a) soit ordonner, pour chaque manquement,
que la contribution pécuniaire d’un exercice
à la province soit réduite du montant qu’il
estime indiqué, compte tenu de la gravité du
manquement;
(a) direct that any cash contribution to that
province for a fiscal year be reduced, in respect of each default, by an amount that the
Governor in Council considers to be appropriate, having regard to the gravity of the default; or
b) soit, s’il l’estime indiqué, ordonner la retenue de la totalité de la contribution pécuniaire d’un exercice à la province.
(b) where the Governor in Council considers
it appropriate, direct that the whole of any
cash contribution to that province for a fiscal
year be withheld.
Amending
orders
(2) The Governor in Council may, by order,
repeal or amend any order made under subsection (1) where the Governor in Council is of the
opinion that the repeal or amendment is warranted in the circumstances.
(2) Le gouverneur en conseil peut, par décret, annuler ou modifier un décret pris en vertu
du paragraphe (1) s’il l’estime justifié dans les
circonstances.
Modification des
décrets
Notice of order
(3) A copy of each order made under this
section together with a statement of any findings on which the order was based shall be sent
forthwith by registered mail to the government
of the province concerned and the Minister
shall cause the order and statement to be laid
before each House of Parliament on any of the
(3) Le texte de chaque décret pris en vertu
du présent article de même qu’un exposé des
motifs sur lesquels il est fondé sont envoyés
sans délai par courrier recommandé au gouvernement de la province concernée; le ministre
fait déposer le texte du décret et celui de l’exposé devant chaque chambre du Parlement dans
Avis
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Commencement
of order
Reimposition of
reductions or
withholdings
When reduction
or withholding
imposed
Extra-billing
first fifteen days on which that House is sitting
after the order is made.
les quinze premiers jours de séance de celle-ci
suivant la prise du décret.
(4) An order made under subsection (1)
shall not come into force earlier than thirty
days after a copy of the order has been sent to
the government of the province concerned under subsection (3).
(4) Un décret pris en vertu du paragraphe (1)
ne peut entrer en vigueur que trente jours après
l’envoi au gouvernement de la province concernée du texte du décret aux termes du paragraphe (3).
R.S., 1985, c. C-6, s. 15; 1995, c. 17, s. 38.
L.R. (1985), ch. C-6, art. 15; 1995, ch. 17, art. 38.
16. In the case of a continuing failure to satisfy any of the criteria described in sections 8 to
12 or to comply with any condition set out in
section 13, any reduction or withholding under
section 15 of a cash contribution to a province
for a fiscal year shall be reimposed for each
succeeding fiscal year as long as the Minister is
satisfied, after consultation with the minister responsible for health care in the province, that
the default is continuing.
16. En cas de manquement continu aux
conditions visées aux articles 8 à 12 ou à l’article 13, les réductions ou retenues de la contribution pécuniaire à une province déjà appliquées pour un exercice en vertu de l’article 15
lui sont appliquées de nouveau pour chaque
exercice ultérieur où le ministre estime, après
consultation de son homologue chargé de la
santé dans la province, que le manquement se
continue.
R.S., 1985, c. C-6, s. 16; 1995, c. 17, s. 39.
L.R. (1985), ch. C-6, art. 16; 1995, ch. 17, art. 39.
17. Any reduction or withholding under section 15 or 16 of a cash contribution may be imposed in the fiscal year in which the default that
gave rise to the reduction or withholding occurred or in the following fiscal year.
17. Toute réduction ou retenue d’une contribution pécuniaire visée aux articles 15 ou 16
peut être appliquée pour l’exercice où le manquement à son origine a eu lieu ou pour l’exercice suivant.
R.S., 1985, c. C-6, s. 17; 1995, c. 17, s. 39.
L.R. (1985), ch. C-6, art. 17; 1995, ch. 17, art. 39.
EXTRA-BILLING AND USER CHARGES
SURFACTURATION ET FRAIS
MODÉRATEURS
18. In order that a province may qualify for
a full cash contribution referred to in section 5
for a fiscal year, no payments may be permitted
by the province for that fiscal year under the
health care insurance plan of the province in respect of insured health services that have been
subject to extra-billing by medical practitioners
or dentists.
18. Une province n’a droit, pour un exercice, à la pleine contribution pécuniaire visée à
l’article 5 que si, aux termes de son régime
d’assurance-santé, elle ne permet pas pour cet
exercice le versement de montants à l’égard des
services de santé assurés qui ont fait l’objet de
surfacturation par les médecins ou les dentistes.
Entrée en
vigueur du
décret
Nouvelle
application des
réductions ou
retenues
Application aux
exercices
ultérieurs
Surfacturation
1984, ch. 6, art. 18.
1984, c. 6, s. 18.
User charges
19. (1) In order that a province may qualify
for a full cash contribution referred to in section 5 for a fiscal year, user charges must not be
permitted by the province for that fiscal year
under the health care insurance plan of the
province.
19. (1) Une province n’a droit, pour un
exercice, à la pleine contribution pécuniaire visée à l’article 5 que si, aux termes de son régime d’assurance-santé, elle ne permet pour cet
exercice l’imposition d’aucuns frais modérateurs.
Frais
modérateurs
Limitation
(2) Subsection (1) does not apply in respect
of user charges for accommodation or meals
provided to an in-patient who, in the opinion of
the attending physician, requires chronic care
and is more or less permanently resident in a
hospital or other institution.
(2) Le paragraphe (1) ne s’applique pas aux
frais modérateurs imposés pour l’hébergement
ou les repas fournis à une personne hospitalisée
qui, de l’avis du médecin traitant, souffre d’une
maladie chronique et séjourne de façon plus ou
Réserve
1984, c. 6, s. 19.
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moins permanente à l’hôpital ou dans une autre
institution.
1984, ch. 6, art. 19.
Deduction for
extra-billing
20. (1) Where a province fails to comply
with the condition set out in section 18, there
shall be deducted from the cash contribution to
the province for a fiscal year an amount that the
Minister, on the basis of information provided
in accordance with the regulations, determines
to have been charged through extra-billing by
medical practitioners or dentists in the province
in that fiscal year or, where information is not
provided in accordance with the regulations, an
amount that the Minister estimates to have been
so charged.
20. (1) Dans le cas où une province ne se
conforme pas à la condition visée à l’article 18,
il est déduit de la contribution pécuniaire à
cette dernière pour un exercice un montant, déterminé par le ministre d’après les renseignements fournis conformément aux règlements,
égal au total de la surfacturation effectuée par
les médecins ou les dentistes dans la province
pendant l’exercice ou, si les renseignements
n’ont pas été fournis conformément aux règlements, un montant estimé par le ministre égal à
ce total.
Déduction en
cas de
surfacturation
Deduction for
user charges
(2) Where a province fails to comply with
the condition set out in section 19, there shall
be deducted from the cash contribution to the
province for a fiscal year an amount that the
Minister, on the basis of information provided
in accordance with the regulations, determines
to have been charged in the province in respect
of user charges to which section 19 applies in
that fiscal year or, where information is not
provided in accordance with the regulations, an
amount that the Minister estimates to have been
so charged.
(2) Dans le cas où une province ne se
conforme pas à la condition visée à l’article 19,
il est déduit de la contribution pécuniaire à
cette dernière pour un exercice un montant, déterminé par le ministre d’après les renseignements fournis conformément aux règlements,
égal au total des frais modérateurs assujettis à
l’article 19 imposés dans la province pendant
l’exercice ou, si les renseignements n’ont pas
été fournis conformément aux règlements, un
montant estimé par le ministre égal à ce total.
Déduction en
cas de frais
modérateurs
Consultation
with province
(3) The Minister shall not estimate an
amount under subsection (1) or (2) without first
undertaking to consult the minister responsible
for health care in the province concerned.
(3) Avant d’estimer un montant visé au paragraphe (1) ou (2), le ministre se charge de
consulter son homologue responsable de la santé dans la province concernée.
Consultation de
la province
Separate
accounting in
Public Accounts
(4) Any amount deducted under subsection
(1) or (2) from a cash contribution in any of the
three consecutive fiscal years the first of which
commences on April 1, 1984 shall be accounted for separately in respect of each province in
the Public Accounts for each of those fiscal
years in and after which the amount is deducted.
(4) Les montants déduits d’une contribution
pécuniaire en vertu des paragraphes (1) ou (2)
pendant les trois exercices consécutifs dont le
premier commence le 1er avril 1984 sont comptabilisés séparément pour chaque province dans
les comptes publics pour chacun de ces exercices pendant et après lequel le montant a été
déduit.
Comptabilisation
Refund to
province
(5) Where, in any of the three fiscal years
referred to in subsection (4), extra-billing or user charges have, in the opinion of the Minister,
been eliminated in a province, the total amount
deducted in respect of extra-billing or user
charges, as the case may be, shall be paid to the
province.
(5) Si, de l’avis du ministre, la surfacturation ou les frais modérateurs ont été supprimés
dans une province pendant l’un des trois exercices visés au paragraphe (4), il est versé à cette
dernière le montant total déduit à l’égard de la
surfacturation ou des frais modérateurs, selon le
cas.
Remboursement
à la province
Saving
(6) Nothing in this section restricts the power of the Governor in Council to make any order under section 15.
(6) Le présent article n’a pas pour effet de
limiter le pouvoir du gouverneur en conseil de
prendre le décret prévu à l’article 15.
Réserve
1984, c. 6, s. 20.
1984, ch. 6, art. 20.
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When deduction
made
21. Any deduction from a cash contribution
under section 20 may be made in the fiscal year
in which the matter that gave rise to the deduction occurred or in the following two fiscal
years.
21. Toute déduction d’une contribution pécuniaire visée à l’article 20 peut être appliquée
pour l’exercice où le fait à son origine a eu lieu
ou pour les deux exercices suivants.
Application aux
exercices
ultérieurs
1984, ch. 6, art. 21.
1984, c. 6, s. 21.
Regulations
REGULATIONS
RÈGLEMENTS
22. (1) Subject to this section, the Governor
in Council may make regulations for the administration of this Act and for carrying its purposes and provisions into effect, including,
without restricting the generality of the foregoing, regulations
22. (1) Sous réserve des autres dispositions
du présent article, le gouverneur en conseil
peut, par règlement, prendre toute mesure d’application de la présente loi et, notamment :
Règlements
a) définir les services visés aux alinéas a) à
d) de la définition de « services complémentaires de santé » à l’article 2;
(a) defining the services referred to in paragraphs (a) to (d) of the definition "extended
health care services" in section 2;
b) déterminer les services exclus des services hospitaliers;
(b) prescribing the services excluded from
hospital services;
c) déterminer les genres de renseignements
dont peut avoir besoin le ministre en vertu de
l’alinéa 13a) et fixer les modalités de temps
et autres de leur communication;
(c) prescribing the types of information that
the Minister may require under paragraph
13(a) and the times at which and the manner
in which that information shall be provided;
and
d) prévoir la façon dont il doit être fait état
du Transfert en vertu de l’alinéa 13b).
(d) prescribing the manner in which recognition to the Canada Health Transfer is required to be given under paragraph 13(b).
Agreement of
provinces
(2) Subject to subsection (3), no regulation
may be made under paragraph (1)(a) or (b) except with the agreement of each of the
provinces.
(2) Sous réserve du paragraphe (3), il ne
peut être pris de règlements en vertu des alinéas
(1)a) ou b) qu’avec l’accord de chaque province.
Consentement
des provinces
Exception
(3) Subsection (2) does not apply in respect
of regulations made under paragraph (1)(a) if
they are substantially the same as regulations
made under the Federal-Provincial Fiscal Arrangements Act, as it read immediately before
April 1, 1984.
(3) Le paragraphe (2) ne s’applique pas aux
règlements pris en vertu de l’alinéa (1)a) s’ils
sont sensiblement comparables aux règlements
pris en vertu de la Loi sur les arrangements fiscaux entre le gouvernement fédéral et les provinces, dans sa version précédant immédiatement le 1er avril 1984.
Exception
Consultation
with provinces
(4) No regulation may be made under paragraph (1)(c) or (d) unless the Minister has first
consulted with the ministers responsible for
health care in the provinces.
(4) Il ne peut être pris de règlements en vertu des alinéas (1)c) ou d) que si le ministre a au
préalable consulté ses homologues chargés de
la santé dans les provinces.
Consultation des
provinces
R.S., 1985, c. C-6, s. 22; 1995, c. 17, s. 40; 2012, c. 19, s.
410(E).
L.R. (1985), ch. C-6, art. 22; 1995, ch. 17, art. 40; 2012, ch.
19, art. 410(A).
REPORT TO PARLIAMENT
RAPPORT AU PARLEMENT
23. The Minister shall, as soon as possible
after the termination of each fiscal year and in
any event not later than December 31 of the
23. Au plus tard pour le 31 décembre de
chaque année, le ministre établit dans les
meilleurs délais un rapport sur l’application de
Annual report by
Minister
Canada Health Act — Annual Report 2012–2013
13
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du ministre
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Canada Health — July 8, 2012
next fiscal year, make a report respecting the
administration and operation of this Act for that
fiscal year, including all relevant information
on the extent to which provincial health care insurance plans have satisfied the criteria, and the
extent to which the provinces have satisfied the
conditions, for payment under this Act and
shall cause the report to be laid before each
House of Parliament on any of the first fifteen
days on which that House is sitting after the report is completed.
la présente loi au cours du précédent exercice,
en y incluant notamment tous les renseignements pertinents sur la mesure dans laquelle les
régimes provinciaux d’assurance-santé et les
provinces ont satisfait aux conditions d’octroi
et de versement prévues à la présente loi; le ministre fait déposer le rapport devant chaque
chambre du Parlement dans les quinze premiers
jours de séance de celle-ci suivant son achèvement.
1984, ch. 6, art. 23.
1984, c. 6, s. 23.
158
14
Canada Health Act — Annual Report 2012–2013
CANADA
CANADA
CONSOLIDATION
CODIFICATION
Extra-billing and User
Charges Information
Regulations
Règlement concernant les
renseignements sur la
surfacturation et les frais
modérateurs
SOR/86-259
DORS/86-259
Current to November 30, 2010
À jour au 30 novembre 2010
Published by the Minister of Justice at the following address:
http://laws-lois.justice.gc.ca
Publié par le ministre de la Justice à l’adresse suivante :
http://lois-laws.justice.gc.ca
Canada Health Act — Annual Report 2012–2013
159
Published
consolidation is
evidence
OFFICIAL STATUS
OF CONSOLIDATIONS
CARACTÈRE OFFICIEL
DES CODIFICATIONS
Subsections 31(1) and (3) of the Legislation
Revision and Consolidation Act, in force on
June 1, 2009, provide as follows:
Les paragraphes 31(1) et (3) de la Loi sur la
révision et la codification des textes législatifs,
en vigueur le 1er juin 2009, prévoient ce qui
suit :
31. (1) Every copy of a consolidated statute or
consolidated regulation published by the Minister
under this Act in either print or electronic form is evidence of that statute or regulation and of its contents
and every copy purporting to be published by the
Minister is deemed to be so published, unless the
contrary is shown.
31. (1) Tout exemplaire d'une loi codifiée ou
d'un règlement codifié, publié par le ministre en vertu de la présente loi sur support papier ou sur support
électronique, fait foi de cette loi ou de ce règlement
et de son contenu. Tout exemplaire donné comme
publié par le ministre est réputé avoir été ainsi publié, sauf preuve contraire.
...
Inconsistencies
in regulations
160
(3) In the event of an inconsistency between a
consolidated regulation published by the Minister
under this Act and the original regulation or a subsequent amendment as registered by the Clerk of the
Privy Council under the Statutory Instruments Act,
the original regulation or amendment prevails to the
extent of the inconsistency.
Codifications
comme élément
de preuve
[...]
(3) Les dispositions du règlement d'origine avec
ses modifications subséquentes enregistrées par le
greffier du Conseil privé en vertu de la Loi sur les
textes réglementaires l'emportent sur les dispositions
incompatibles du règlement codifié publié par le ministre en vertu de la présente loi.
Incompatibilité
— règlements
Canada Health Act — Annual Report 2012–2013
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.
Canada Health Act — Annual Report 2012–2013
1
161
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
162
Canada Health Act — Annual Report 2012–2013
ANNEX B
POLICY INTERPRETATION LETTERS
There are two key policy statements that clarify the federal
position on the Canada Health Act. These statements have
been made in the form of min­isterial letters from former
Federal Health Ministers to their provincial and territorial
counterparts.
Epp Letter
In June 1985, approximately one year following the passage
of the Canada Health Act in Parliament, then-federal Health
Minister Jake Epp wrote to his provincial and territorial
counterparts to set out and confirm the federal position
on the interpretation and implementation of the Canada
Health Act.
Minister Epp’s letter followed several months of consultation
with his provincial and territorial counterparts. The letter
sets forth statements of federal policy intent which clarify
the criteria, conditions and regulatory provisions of the
Canada Health Act. These clarifications have been used by
the federal government in the assessment and interpretation
of compliance with the Act. The Epp letter remains an important reference for interpretation of the Act.
Canada Health Act — Annual Report 2012–2013
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 Federal/Provincial/Territorial Health Ministers
Meeting of September 1994 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.
163
Annex B: Policy Interpretation Letters
[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 physicaland 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
164
Canada Health Act — Annual Report 2012–2013
Annex B: Policy Interpretation Letters
and out-patient hospital services associated with the provision of acute, rehabilitative and chronic care. As regards physician
services, the range of insured 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.
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.
Canada Health Act — Annual Report 2012–2013
165
Annex B: Policy Interpretation Letters
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.
166
Canada Health Act — Annual Report 2012–2013
Annex B: Policy Interpretation Letters
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
Canada Health Act — Annual Report 2012–2013
167
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 pro­vision 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 outpatient 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 pro­vides
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 regu­
latory 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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Canada Health Act — Annual Report 2012–2013
Annex B: Policy Interpretation Letters
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
Canada Health Act — Annual Report 2012–2013
169
170
Canada Health Act — Annual Report 2012–2013
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
government-to-government fact-finding and negotiations.
Canada Health Act — Annual Report 2012–2013
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.
171
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.
172
Canada Health Act — Annual Report 2012–2013
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
Canada Health Act — Annual Report 2012–2013
173
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:
• participate actively in ad hoc federal/provincial/terri­
torial committees on Canada Health Act issues; and
• undertake government-to-government information
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 accor-
dance with the provisions of the Canada Health Act,
will undertake fact-finding and provide advice and
recommendations.
• The panel will then report to the governments involved
on the issue within 60 days of appointment.
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
non-compliance provisions of the Act.
Governments will report publicly on Canada Health Act dispute avoidance and resolution activities, including any panel
report.
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:
•
•
•
•
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.
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.
174
Canada Health Act — Annual Report 2012–2013
Contact Information for Provincial and Territorial Departments of Health
Newfoundland and Labrador
Manitoba
Department of Health and Community Services
Confederation Building
P.O. Box 8700
St. John’s, NL A1B 4J6
(709) 729-5021
www.gov.nl.ca/health
Manitoba Health
300 Carlton Street
Winnipeg, MB R3B 3M9
1-800-392-1207
www.manitoba.ca/health
Prince Edward Island
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)
http://novascotia.ca/DHW
New Brunswick
Department of Health
P.O. Box 5100
Fredericton, NB E3B 5G8
(506) 457-4800
www.gnb.ca/0051/index-e.asp
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
Saskatchewan Health
3475 Albert Street
Regina, SK S4S 6X6
1-800-667-7766
www.health.gov.sk.ca
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/
CANADA HEALTH ACT
CANADA HEALTH ACT
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