CANADA HEALTH ACT 2011–2012 ANNUAL REPORT ANNUAL

CANADA HEALTH ACT 2011–2012 ANNUAL REPORT ANNUAL
CANADA HEALTH ACT
CANADA HEALTH ACT
Public Administration
Comprehensiveness
Universality
Portability
ANNUAL REPORT 2011–2012
ANNUAL REPORT
2011–2012
Accessibility
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 2011–2012
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 2011-2012
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For further information or to obtain additional copies, please contact:
Health Canada
Address Locator 0900C2
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Fax: (613) 941-5366
© Majesty the Queen in Right of Canada, represented by the Minister of Health of Canada, 2012
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]ca
HC Pub: 120143
Cat.: H1-4/2012E
ISSN: 0842-3202
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 and Social Services
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 2011–2012
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Canada Health Act — Annual Report 2011–2012
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 2011–2012_____________________________________ 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___________________________________________________________________________ 101
Yukon___________________________________________________________________________________ 113
Northwest Territories_______________________________________________________________________ 123
Nunavut__________________________________________________________________________________ 131
Annex A — Canada Health Act and Extra-Billing and User Charges Information Regulations_________________________ 139
Annex B — Policy Interpretation Letters___________________________________________________________________ 161
Annex C — Dispute Avoidance and Resolution Process under the Canada Health Act________________________________ 169
Provincial and Territorial Departments of Health Contact Information________________________________ inside back cover
Canada Health Act — Annual Report 2011–2012
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Canada Health Act — Annual Report 2011–2012
Introduction
INTRODUCTION
Canada has a predominantly publicly financed and admini­
stered 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.
The roles and responsibilities for Canada’s health care system
are shared between the federal and provincial/territorial
governments. The provincial and territorial governments have
primary jurisdiction in the administration and delivery of
health care services. This includes setting their own priorities,
administering their health care budgets and managing their
own resources. The federal government, under the Canada
Health Act, sets out the criteria and conditions that must be
satisfied by the provincial and territorial health insurance
plans for provinces and territories to qualify for their full
share of the cash contribution available to them under the
federal Canada Health Transfer.
On an annual basis, the federal Minister of Health is required
to report to Parliament on the administration and operation
of the Canada Health Act, as set out in section 23 of the Act.
The vehicle for so doing is the Canada Health Act Annual
Report. While the principal and intended audience for 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.
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 fees 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.
Provincial and territorial health care insurance plans generally
respect the criteria and conditions of the Canada Health Act
and many exceed the requirements of the Act. However, when
instances of possible non-compliance with the Act arise, Health
Canada’s approach to the administration of the Act emphasizes
transparency, consultation and dialogue with provincial and
territorial health care ministries. The application of financial
penalties through deductions under the Canada Health Transfer
is considered only as a last resort when all other options to
resolve an issue collaboratively have been exhausted. Pursuant
to the commitment made by premiers under the 1999 Social
Union Framework Agreement, federal, provincial and territorial
governments (except Quebec) agreed through an exchange of
letters, in April 2002, to a Canada Health Act Dispute Avoidance
and Resolution (DAR) process. The DAR process was formalized
in the First Ministers’ 2004 Accord. Although the DAR process
includes dispute resolution provisions, the federal Minister of
Health retains the final authority to interpret and enforce the
Canada Health Act.
The Canada Health Act is Canada’s federal health insurance
legislation and defines the national principles that govern the
Canadian health insurance system, namely, public admini­
stration, comprehensiveness, universality, portability and
accessibility. These principles are symbols of the underlying
Canadian values of equity and solidarity.
In 2011–2012, the most prominent concerns with respect
to compliance under the Canada Health Act remained
concerning patient charges for medically necessary services
in private clinics, and queue jumping. Health Canada has
made these concerns known to the provinces that allow
these charges.
Canada Health Act — Annual Report 2011–2012
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Canada Health Act — Annual Report 2011–2012
Chapter 1: Canada Health Act Overview
Key Definitions Under the Canada Health Act
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 direct charges related
to the provision of insured health services.
Insured persons are eligible residents of a province or territory. A resident of a province is defined in the Act as “a person
lawfully entitled to be or to remain in Canada who makes his
home and is ordinarily present in the province, but does not
include a tourist, a transient or a visitor to the province.”
Persons excluded under the Act include serving members
of the Canadian Forces or Royal Canadian Mounted Police1
and inmates of federal penitentiaries.
Insured health services are medically necessary hospital,
physician and surgical-dental services (performed by a
dentist in a hospital, where a hospital is required for the
proper performance of the procedure) provided to insured
persons.
Insured hospital services are defined under the Act and
include medically necessary in- and out-patient services
such as accommodation and meals at the standard or public ward level and preferred accommodation if medically
required; nursing service; laboratory, radiological and
other diagnostic procedures, together with the necessary
interpretations; drugs, biologicals and related preparations
when administered in the hospital; use of operating room,
case room and anaesthetic facilities, including necessary
equipment and supplies; medical and surgical equipment and
supplies; use of radiotherapy facilities; use of physiotherapy
facilities; and services provided by persons who receive
remuneration 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 physicians in conjunction with
their provincial and territorial health insurance plans.
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.
1. On June 29, 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.
Canada Health Act — Annual Report 2011–2012
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Chapter 1: Canada Health Act Overview
Requirements of the
Canada Health Act
The Canada Health Act contains nine requirements that the
provinces and territories must fulfill in order to qualify for
the full amount of their cash entitlement under the CHT.
They are:
• five program criteria that apply only to insured health
services;
• two conditions that apply to insured health services and
extended health care services; and
• extra-billing and user charges provisions that apply only
to insured health services.
The Criteria
1. Public Administration (section 8)
The public administration criterion, set out in section 8 of the
Canada Health Act, applies to provincial and territorial health
care insurance plans. The intent of the public administration
criterion is that the provincial and territorial health care insurance plans 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 administrative services necessary for
the administration of the provincial and territorial health care
insurance plans.
The public administration criterion pertains only to the
administration of provincial and territorial health insurance
plans and does not preclude private facilities or providers
from supplying insured health services as long as no eligible
resident 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) and, where the law of the province
so permits, similar or additional services rendered by other
health care practitioners.
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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 plans to establish entitlement.
Newcomers to Canada, such as immigrants or Canadians
returning from other countries to live in Canada, may be
subject to a waiting period by a province or territory, not
to exceed three months, before they are entitled to receive
insured health services.
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 imposed
by the new province or territory of residence. The waiting
period for eligibility to a provincial or territorial health care
insurance plan must not exceed three months. After the
waiting period, the new province or territory of residence
assumes responsibility for health care coverage. However, it
is the responsibility of residents to inform their province or
territory’s health care insurance plan that they are leaving and
to register with the health care insurance plan of their new
province or territory.
Residents who are temporarily absent from their home
province or territory or from Canada, must continue to be
covered for insured health services during their absence.
This allows individuals to travel or be absent from their
home province or territory, within a prescribed duration,
while retaining their health insurance coverage.
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.
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.
Prior approval by the health care insurance plan in a
person’s home province or territory may be required before
Canada Health Act — Annual Report 2011–2012
Chapter 1: Canada Health Act Overview
coverage is extended for elective (non-emergency) services
to a resident while temporarily absent from his or 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).
In addition, 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.
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.
The Conditions
1. Information (section 13(a))
The provincial and territorial governments shall provide
information to the federal Minister of Health as may be
reasonably required, in relation to insured health services and
extended health care services, for the purposes of the Act.
2. Recognition (section 13(b))
The provincial and territorial governments shall
recognize the federal financial contributions toward
both insured and extended health care services.
under the Act. The amount of such a deduction for a fiscal
year is determined by the federal Minister of Health based
on information provided by the province or territory in accordance with the Extra-billing and User Charges Information
Regulations (described below).
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
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 that is permitted by a
provincial or territorial health care insurance plan and is not
payable by the plan. For example, if patients were charged
a facility fee for receiving an insured service at a hospital
or clinic, that fee would be considered a user charge. User
charges are not permitted under the Act because, as is the
case with extra-billing, they constitute a barrier or impediment to access.
Other Elements of the Act
Regulations (section 22)
Section 22 of the Canada Health Act enables the federal
government to make regulations for administering the Act
in the following areas:
• defining the services included in the Act’s definition of
“extended health care services”;
• prescribing which services to exclude from
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
Canada Health Act — Annual Report 2011–2012
hospital services;
• prescribing the types of information that the federal
Minister of Health may reasonably require, and the times
at which, and the manner in which, that information may
be provided; and
• prescribing how provinces and territories are required
to recognize the CHT in their documents, advertising or
promotional materials.
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Chapter 1: Canada Health Act Overview
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 so that appropriate penalties can be
levied. They must also provide financial statements showing
the amounts actually charged so that reconciliations with any
estimated charges can be made. (A copy of these regulations
is provided in Annex A.)
Excluded Services
Penalty Provisions of the Canada Health Act
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 provincial and territorial health insurance plans.
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.
For example, this means that when it has been determined that
a province or territory has allowed $500,000 in extra-billing
by physicians, the federal cash contribution to that province
or territory will be reduced by that same amount.
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 gravity of the default.
The Canada Health Act sets out a consultation process
that must be undertaken with the province or territory
before discretionary penalties can be levied. To date,
the discretionary penalty provisions of the Act have not
been applied.
Excluded Services and Persons
Although the Canada Health Act requires that insured health
services be provided to insured persons in a manner that is
consistent with the criteria and conditions set out in the Act,
not all Canadian residents or health services fall under the
scope of the Act. There are two categories of exclusions:
• services that fall outside the definition of insured health
services; and
• certain services and groups of persons are excluded from
the definitions of insured services and insured persons.
These exclusions are discussed in the following section.
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.
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., refugees) or under the workers’
compensation legislation of a province or territory.
Excluded Persons
The Canada Health Act definition of “insured person” excludes
members of the Canadian Forces, persons appointed to a
position of rank within the Royal Canadian Mounted Police2
and persons serving a term of imprisonment within a federal
penitentiary. The Government of Canada provides coverage
to these groups through separate federal programs.
As well, other categories of residents such as landed immigrants and Canadians returning from other countries to live
in Canada may be subject to a waiting period by a province
or territory. The Act stipulates that the waiting period cannot
exceed three months.
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.
2. On June 29, 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.
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Canada Health Act — Annual Report 2011–2012
Chapter 1: Canada Health Act Overview
There is a Frequently Asked Questions link on Health Canada’s
website 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
Canada Health Act — Annual Report 2011–2012
services at private clinics. The letter stated that the definition
of “hospital” contained in the Act includes any public facility
that provides acute, rehabilitative or chronic care. Thus, when
a provincial or territorial health insurance plan pays the physician fee for a medically necessary service delivered at a private
clinic, it must also pay the facility fee or face a deduction from
federal transfer payments.
Dispute Avoidance and
Resolution Process
In April 2002, 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
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
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Chapter 1: Canada Health Act Overview
used to build up the Canadian hospital infrastructure, they also
supported initiatives in areas such as professional training, public health research, tuberculosis control and cancer treatment.
By the mid-1960s, the grants available to the provinces totalled
more than $60 million annually.
In the mid-1950s in response to public pressures, the federal
government agreed to provide financial assistance to provinces to
help them establish health insurance programs. In January 1956,
the federal government placed concrete proposals before the
provinces to inaugurate a phased health insurance program,
with priority given to hospital insurance and diagnostic services.
Discussions on these proposals led to adopting the Hospital
Insurance and Diagnostic Services Act in 1957. The implementation of the Hospital Insurance and Diagnostic Services (HIDS)
program 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. 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.
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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 FederalProvincial Fiscal Arrangements and Established Programs
Financing Act, 1977. Known also as the EPF Act, the new
legislation provided federal contributions to the provinces
and territories for insured hospital and medical care services
(as well as for post-secondary education) that were no longer
tied to provincial expenditures. Rather, federal contributions
made in fiscal year 1975-1976 under the existing cost-sharing
programs were designated as the base year for contributions, to
be escalated by the rate of growth of nominal Gross National
Product and increases to the population.
Under the EPF Act, and subsequent funding arrangements, the
total amount of the provincial and territorial health entitlement was made up of relatively equal cash and tax transfers.
The federal tax transfer involves the federal government ceding
some of its “tax room” to the provincial and territorial governments, reducing its tax rate to allow provinces to raise their tax
rates by an equivalent amount. With the Established Programs
Financing (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 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 conditions were not met. It was not until the enactment of the Canada
Health Act in 1984 that special deduction provisions came into
force allowing for dollar-for-dollar deductions for 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 Act — Annual Report 2011–2012
Chapter 1: Canada Health Act Overview
Canada Health and Social Transfer
In the 1995 Budget, the federal government announced a
restructuring of the EPF Act, then to be called the FederalProvincial 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 costsharing arrangement for social services). When the CHST came
into effect on April 1, 1996, provinces and territories received
CHST cash and tax transfer in lieu of entitlements under the
Canada Assistance Plan (CAP) and EPF. The new CHST cash
amount provided to provinces and territories was less than the
combined values of EPF and CAP, reflecting the need for fiscal
restraint at the time the CHST was introduced. The 1995 and
1996 Budget legislation provided for total CHST amounts (cash
and tax transfers) for the following years, with an annual floor of
$11 billion for the cash component to apply until 2002–2003.
The new block fund was provided to uphold the national
criteria in the Canada Health Act (public administration,
comprehensiveness, universality, portability and accessibility)
and the provisions relating to extra-billing and user charges,
as well as maintaining the CAP-related national standard
that no period of minimum residency be required or allowed
with respect to social assistance. Extended health care services continued as part of the Act, subject only to providing
information and recognizing the federal transfer, as set out
in section 13 of the Act. These requirements have remained
unchanged since 1984.
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:
• for determining the amounts of any deductions pursuant
to the extra-billing and user charges provisions of the Act;
and
• for 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
Canada Health Act — Annual Report 2011–2012
through a trust fund notionally allocated over three years to
provide provinces and territories flexibility over when to draw
down the funds. Budget 2000 then provided an additional
$2.5 billion for health care through another trust fund to
provinces and territories, notionally allocated over four years.
2000 and 2003 Health Accords: Increasing and Restructuring
Federal Support for Health
In 2000 and 2003, First Ministers met to discuss health care,
focusing on reform, reporting and funding requirements.
In 2000, the federal government announced $23.4 billion
in new spending over five years on health care renewal and
early childhood development. This included an additional
$21.1 billion dollars in increases to the CHST cash contributions, as well as an additional $1.8 billion for targeted
programs (medical equipment and primary health care
reform), and $500 million for Canada Health Infoway.
In 2003, the government committed $36.8 billion over five
years to support priority areas of health reform (primary care,
home 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.
9
Chapter 1: Canada Health Act Overview
2004 10-year Plan to Strengthen Health Care
Recent Transfer Changes
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.
As announced by the Government of Canada in December 2011,
and legislated in the Jobs, Growth and Long-term Prosperity Act,
the CHT will continue to grow at an annual rate of 6 percent
for an additional three years beyond 2013–2014 (i.e., until
2016–2017). Starting in 2017–2018, the CHT will grow in line
with a three-year moving average of nominal gross domestic
product growth, with funding guaranteed to increase by at
least three percent per year. This will see health transfers
reach historic levels of an estimated $40 billion by the end
of the decade.
Budget 2007
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.
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.
10
Additional information on federal/provincial/territorial
funding arrangements is available upon request from the
Department of Finance, or by visiting its website at:
http://www.fin.gc.ca/access/fedprov-eng.asp#Major
Canada Health Act — Annual Report 2011–2012
Chapter 2: Administration and Compliance
• 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
CHAPTER 2
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.
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.
Health Canada works with the provinces and territories to
ensure that the principles of the Act are respected and always
strives to resolve issues through consultation, collaboration
and cooperation.
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
fulfil 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 insurance
issues received by telephone, mail and the Internet, from the
public, members of Parliament, government departments,
stakeholder organizations and the media;
• developing and maintaining formal and informal part-
nerships 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;
Canada Health Act — Annual Report 2011–2012
Interprovincial Health Insurance Agreements
Coordinating Committee
The Canada Health Act Division chairs the Interprovincial
Health Insurance Agreements Coordinating Committee and
provides a secretariat for the Committee (IHIACC). 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.
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, parti­
cipate in reciprocal medical agreements. The intent of these
agreements is to ensure that Canadian residents do not face
point-of-service charges for medically required hospital and
physician services when they travel in Canada. However,
these agreements are interprovincial/territorial and are not
required by the Act.
Compliance
Health Canada’s approach to resolving possible compliance
issues emphasizes transparency, consultation and dialogue
with provincial and territorial health ministry officials. In
most instances, issues are successfully resolved through
consultation and discussion based on a thorough examination of the facts. To date, most disputes and issues related to
administering and interpreting the Canada Health Act have
11
Chapter 2: Administration and Compliance
been addressed and resolved without resorting to deductions.
Deductions have only been applied when all options to resolve
an issue have been exhausted.
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 non-governmental organizations.
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 mis-communication,
such as eligibility for health insurance coverage and portability of health services within and outside Canada, and are
resolved quickly with provincial or territorial assistance.
In instances where a Canada Health Act issue has been
identified and remains after initial enquiries, Division officials
ask the jurisdiction in question to investigate the matter and
report back. Division staff discuss the issue and its possible
resolution with provincial/territorial officials. Only if the issue
is not resolved to the satisfaction of the Division after following
the aforementioned steps, is it brought to the attention of the
federal Minister of Health.
Compliance Issues
For the most part, provincial and territorial health care insurance
plans meet the criteria and conditions of the Canada Health
Act. However, on the basis of reports to Health Canada by their
respective provincial health ministries, deductions were taken
from the March 2012 Canada Health Transfer (CHT) payments
to British Columbia, in respect of extra-billing and patient
charges at surgical clinics, in the amount of $33,219, and
Newfoundland and Labrador, in respect of extra-billing and
user charges for insured surgical-dental services in the amount
of $45,329, levied during fiscal year 2009–2010. Additionally,
a deduction of $13,350 was taken from Newfoundland and
Labrador’s September 2011 CHT payment as a result of a statement received from that province for estimated extra-billing and
user charges during 2011–2012.
In 2011–2012, Health Canada officials raised a number of
issues with some provincial health ministries, primarily
concerning patient charges for medically necessary services
in private clinics, and queue jumping.
12
In March 2011, media reports indicated that a private primary
care clinic in Calgary that charges its clients an enrollment and
annual membership fee was offering its members preferred
access to physicians for insured services, including after-hours
service. Health Canada subsequently contacted Alberta Health
and Wellness to express concerns that receiving insured services
might be conditional upon the payment of fees, which would
pose concerns under the accessibility criterion of the Act. Alberta
Health and Wellness conducted an investigation into the clinic
and in 2012 assured Health Canada that membership in the
clinic is not a requirement for access to insured services and
that members do not receive expedited or preferential access
to insured services. Alberta Health and Wellness has also indicated that the Ministry will 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.
In June 2011, at the request of members of the legislative
assembly, the RCMP investigated media allegations that
Alberta Health Services had arranged for expedited access to
insured health services for VIPs. Health Canada contacted
Alberta Health and Wellness officials to express concerns over
these allegations. In responding to Health Canada, Alberta
Health and Wellness officials noted that the RCMP concluded
that there was not a sufficient case for a criminal investigation
and stated that the Alberta government had invited any person with knowledge of such practices to come forward, but
none had. On February 28, 2012, the Government of Alberta
announced that a public inquiry into allegations of queue
jumping would be conducted in accordance with the Health
Quality Council of Alberta Act, and appointed a commissioner
to lead the inquiry in March 2012. Health Canada continues
to monitor this situation.
In August 2011, Health Canada learned of a Toronto clinic
that advertised 24-hour access to physicians and assistance
with emergency room visits in exchange for an annual fee,
and an Ottawa clinic that charged an annual fee for access
to family physicians, as well as expedited specialist appointments, imaging and surgery. In both cases, Health Canada
officials contacted officials at the Ontario Ministry of Health
and Long-Term Care (MOHLTC) to raise concerns that
patients could be charged for insured services and that access
to insured services might be expedited for those paying such
fees. The MOHLTC advised that they would investigate and
take decisive, corrective action pursuant to the requirements
of Ontario’s Commitment to the Future of Medicare Act,
if necessary.
In August 2011, Health Canada learned about a Whitby,
Ontario paediatrician who was charging an annual membership fee in exchange for after-hours access to insured services
and was refusing to take on patients who were not willing to
pay the fee. That same month, the College of Physicians and
Canada Health Act — Annual Report 2011–2012
Chapter 2: Administration and Compliance
Surgeons of Ontario (CPSO) laid disciplinary charges against
the physician. In June 2012, the Discipline Committee of
the CPSO found that the membership fee failed to comply
with the College’s policy on Block Fees and Uninsured Services.
Health Canada is currently in consultation with the MOHLTC
to confirm that any user charges will be refunded to patients.
In February 2012, the Régie de l’assurance maladie du Québec
(RAMQ) concluded its investigation of a Montreal clinic that
had charged patients for services which are supposed to be
fully covered under the provincial health insurance plan. The
Régie’s report noted that patients were charged for package
deals called “forfait santé” as well as for accessory fees not
allowed by RAMQ. The report noted that patients may apply to
RAMQ for reimbursement and that RAMQ will then collect
the money from the clinic. Health Canada expressed concerns
over these fees with Quebec officials in March 2012 and is
satisfied that RAMQ has addressed this issue by directing the
clinic to change its practices in this regard.
In February 2012, the media reported that the Quebec Health
Minister had requested that the Quebec College of Physicians
investigate reports that some surgeons were advising patients
that they could pay to have their surgeries done more quickly in
the private system. Health Canada contacted Quebec officials
in February 2012 to express concerns over these practices and
continues to monitor the situation.
In February 2012, British Columbia asked Health Canada
about the applicability of the Canada Health Act to a facility
proposed to be built on a First Nations reserve. The federal
Minister of Health confirmed that since the Act applies to all
insured persons, including members of First Nations living on
and off reserve, that the province has the jurisdiction and the
responsibility for ensuring that the facility operates in a manner
consistent with the requirements of the Canada Health 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 extra-billing and user charges,
the federal government took steps to eliminate the proliferation of direct charges for hospital and physician services,
judged to be restricting the access of many Canadians to
health care services due to financial considerations.
Canada Health Act — Annual Report 2011–2012
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 were 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.
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. Including deduction adjustments for prior
years, dating back to fiscal year 1992–1993, deductions began
in May 1994 and continued until extra-billing by physicians
was banned when changes to British Columbia’s Medicare
Protection Act came into effect in September 1995. In total,
$2,025,000 was deducted from British Columbia’s cash
contribution for extra-billing that occurred in the province
between 1992–1993 and 1995–1996. These deductions were
non-refundable, as were all subsequent deductions.
In January 1995, 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 communication with
the provinces and territories, Minister Marleau announced
that the provinces and territories would be given more than
nine months to eliminate these user charges, but that any
province that did not, would face financial penalties under the
Canada Health Act. Accordingly, beginning in November 1995,
deductions were applied to the cash contributions to Alberta,
Manitoba, Nova Scotia and Newfoundland and Labrador for
non-compliance with the Federal Policy on Private Clinics.
From November 1995 to June 1996, total deductions of
$3,585,000 were made to Alberta’s cash contribution in
respect of facility fees charged at clinics providing surgical,
ophthalmological and abortion services. On October 1, 1996,
13
Chapter 2: Administration and Compliance
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 Canada Health and Social Transfer (CHST)
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 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 Health Canada estimated to have been
charged during fiscal year 2001–2002.
Since 2005, the following deductions have been taken from
British Columbia’s CHT payments1 on the basis of charges
reported by the province for extra-billing and user charges
(the fiscal year to which the deductions pertain are indicated in parentheses): $72,464 in March 2005 (2002–2003);
$29,019 in March 2006 (2003–2004); $114,850 in March
2007 (2004–2005); $42,113 in March 2008 (2005–2006);
$66,195 in March 2009 (2006–2007); $73,925 in March
2010 (2007–2008), $75,136 in March 2011 (2008–2009)
and $33,219 in March 2012 (2009–10).
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.
As a result of charges reported by the province to Health Canada,
a deduction of $3,577 was taken from the March 2011 CHT payment to Newfoundland and Labrador for extra-billing and user
charges that occurred during fiscal year 2008–2009. Based on
a statement received from the province estimating user charges
and extra-billing that would occur in 2011–2012, a deduction of
$13,350 was made from the September 2011 CHT payment to
Newfoundland and Labrador. Finally, a $45,329 deduction was
taken from the March 2012 CHT payment to Newfoundland and
Labrador for charges that occurred during fiscal year 2009–2010,
as a result of charges reported by the province to Health Canada.
Since the passage of the Canada Health Act, from April 1984
to March 2012, deductions totalling $9,326,230 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 extra-billing and user
charges were eliminated.
1. The CHT resulted from the division of the Canada Health and Social Transfer (CHST) into two transfers, the Canada Health Transfer (CHT) and the Canada Social
Transfer (CST), which became effective April 1, 2004.
14
Canada Health Act — Annual Report 2011–2012
Chapter 2: Administration and Compliance
Deductions and refunds to CHST/CHT cash contributions in accordance with the Canada Health Act
since 1994–1995 (in dollars)
Province/
Territory
1994–1995
1995–1996
1996–1997
1997–1998
1998–1999
1999–2000
2000–2001
2001–2002
2002–2003
2003–2004
NL
0
46,000
96,000
128,000
53,000
(42,570)
0
0
0
0
PEI
0
0
0
0
0
0
0
0
0
0
NS
0
32,000
72,000
57,000
38,950
61,110
57,804
35,100
11,052
7,119
NB
0
0
0
0
0
0
0
0
0
0
QC
0
0
0
0
0
0
0
0
0
0
ON
0
0
0
0
0
0
0
0
0
0
MB
0
269,000
588,000
586,000
612,000
0
0
300,201
0
0
SK
0
0
0
0
0
0
0
0
0
0
AB
0
2,319,000
1,266,000
0
0
0
0
0
0
0
BC
1,982,000
43,000
0
0
0
0
0
0
4,610
126,775
YK
0
0
0
0
0
0
0
0
0
0
NWT
0
0
0
0
0
0
0
0
0
0
NU
0
0
0
0
0
0
0
0
0
0
1,982,000
2,709,000
2,022,000
771,000
703,950
18,540
57,804
335,301
15,662
133,894
Total
Province/
Territory
2004–2005
2005–2006
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
Total
NL
1,100
0
0
0
0
0
3,577
58,679
343,786
PEI
0
0
0
0
0
0
0
0
0
NS
5,463
(8,121)
9,460
0
0
0
0
0
378,937
NB
0
0
0
0
0
0
0
0
0
QC
0
0
0
0
0
0
0
0
0
ON
0
0
0
0
0
0
0
0
0
MB
0
0
0
0
0
0
0
0
2,355,201
SK
0
0
0
0
0
0
0
0
0
AB
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
2,663,306
YK
0
0
0
0
0
0
0
0
0
NWT
0
0
0
0
0
0
0
0
0
NU
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
9,326,230
Total
Note: Deductions taken in a given year are made from that year’s CHST/CHT payments and are reported in the Canada Health Act Annual Report for that fiscal year.
Deductions made in one fiscal year may include adjustments to previous fiscal years.
Canada Health Act — Annual Report 2011–2012
15
16
Canada Health Act — Annual Report 2011–2012
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2011–2012
CHAPTER 3
Provincial and
Territorial Health
Care Insurance
Plans in 2011–2012
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
2011–2012.
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 docu­
ment; Canada Health Act Annual Report 2011–2012: A Guide
Canada Health Act — Annual Report 2011–2012
for Updating Submissions (User’s Guide). This guide is designed
to help provinces and territories meet the reporting requirements
of Health Canada. 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
2011–2012 was launched late spring 2012 with bilateral teleconferences with each jurisdiction. An updated User’s Guide
was also sent to the provinces and territories at that time.
Insurance Plan Descriptions
For the following chapter, provincial and territorial officials
were asked to provide a narrative description of their health
insurance plan. The descriptions follow the program criteria
areas of the Canada Health Act in order to illustrate how the
plans satisfy these criteria. This narrative format also allows
each jurisdiction to indicate how it met the Canada Health Act
requirement for the recognition of federal contributions that
support insured and extended health care services.
Provincial and Territorial Health Care
Insurance Plan Statistics
Over time, the section of the annual report containing the
statistical information submitted from the provinces and terri­
tories 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 admini­
stration 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, 2012. 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 2011–2012
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 2011–2012
Chapter 3: Newfoundland and Labrador
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.
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, approximately 20,000 health
care providers and administrators provide health services to
over 500,000 residents.
Budget 2011–2012, “People and Prosperity – Responsible
Investments for a Secure Future,” included nearly $3 billion to
improve health care for all residents. Budget 2012 investments
demonstrate a continued commitment to health care throughout Newfoundland and Labrador while balancing responsibility
to ensure the ongoing sustainability of the health care system.
Budget 2012 investments focus on priority areas of dialysis,
addressing drug costs, enhancing breast cancer screening,
increasing access and improving infrastructure.
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
Canada Health Act — Annual Report 2011–2012
The MCP facilitates the delivery of comprehensive medical
care to all residents of the province by implementing policies,
procedures and systems that permit appropriate compensation to providers for rendering insured professional services.
The MCP operates in accordance with the provisions of the
Medical Care Insurance Act, 1999 and regulations, and in
compliance with the Canada Health Act.
There were no legislative amendments to the Medical Care
Insurance Act, 1999 or the Hospital Insurance Agreement Act
in 2011–2012.
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 eight 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 2011–2012 HCS Annual Report was tabled September 28,
2012.
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.
19
Chapter 3: Newfoundland and Labrador
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 were carried out by personnel from the Department
under the authority of the Medical Care Insurance Act, 1999.
Physician records and professional medical corporation
records were reviewed to ensure that the records supported
the services billed and that the services are insured under
the MCP.
Beneficiary audits were performed by personnel from the
Department under the Medical Care Insurance Act, 1999.
Individual providers are randomly selected on a bi-weekly
basis for audit.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
The Hospital Insurance Agreement Act and the Hospital
Insurance Regulations, made thereunder, provide for
insured hospital services in Newfoundland and Labrador.
Insured hospital services are provided for in- and out-patients in
15 hospitals, 22 community health centres and 14 community
clinics. 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 2011–2012.
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.
20
In 2011–2012, there were 1,115 physicians registered
in the province.
For purposes of the Act, the following services are covered:
• all services properly and adequately provided by physicians
to beneficiaries suffering from an illness requiring medical
treatment or advice;
• group immunizations or inoculations carried out by physicians at the request of the appropriate authority; and
• diagnostic and therapeutic x-ray and laboratory services
in facilities approved by the appropriate authority that are
not provided under the Hospital Insurance Agreement Act
and regulations made under the Act.
Physicians can choose not to participate in the health care
insurance plan as outlined in section 12(1) of the Medical
Care Insurance Act, 1999, namely:
12 (1) Where a physician providing insured services is not
a participating physician, and the physician provides an
insured service to a beneficiary, the physician is not subject
to this Act or the regulations relating to the provision of
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, 2012, 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. There were no services
Canada Health Act — Annual Report 2011–2012
Chapter 3: Newfoundland and Labrador
added or deleted during the 2011–2012 fiscal year to the list
of insured physician services.
• the dispensing by a physician of medicines, drugs or
2.3 Insured Surgical-Dental Services
• the preparation by a physician of records, reports or cer-
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.
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, 2012, there were no opted-out
dentists.
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.
medical appliances and the giving or writing of medical
prescriptions;
tificates for, or on behalf of, or any communication to, or
relating to, a beneficiary;
• any services rendered by a physician to the spouse and
children of the physician;
• any service to which a beneficiary is entitled under an
Act of the Parliament of Canada, an Act of the Province
of Newfoundland and Labrador, an Act of the legislature
of any province of Canada, or any law of a country or
part of a country;
• the time taken or expenses incurred in travelling to
consult a beneficiary;
• ambulance service and other forms of patient
transportation;
• acupuncture and all procedures and services related to
acupuncture, excluding an initial assessment specifically
related to diagnosing the illness proposed to be treated
by acupuncture;
Addition of a surgical-dental service to the list of insured
services must be approved by the Minister.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Hospital services not covered by MCP include: preferred
accommodation at the patient’s request; cosmetic surgery
and other services deemed to be medically unnecessary;
ambulance or other patient transportation before admission or upon discharge; private duty nursing arranged by
the patient; non-medically required x-rays or other services for employment or insurance purposes; drugs (except
anti-rejection and AZT drugs) and appliances issued for use
after discharge from hospital; bedside telephones, radios
or television sets for personal, non-teaching use; fibreglass
splints; services covered by the Workplace Health, Safety
and Compensation Commission or by other federal or
provincial legislation; and services relating to therapeutic
abortions performed in non-accredited facilities or facilities
not approved by the College of Physicians and Surgeons of
Newfoundland and Labrador.
The use of the hospital setting for any services deemed not
insured by the MCP are also uninsured under the Hospital
Insurance Plan. For purposes of the Medical Care Insurance
Act, 1999, the following is a list of non-insured physician
services:
• any advice given by a physician to a beneficiary by
telephone;
• 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;
• testimony in a court;
• visits to optometrists, general practitioners and ophthal­
mologists solely for determining whether new or
replacement glasses or contact lenses are required;
• the fees of a dentist, oral surgeon or general practitioner
for routine dental extractions performed in hospital;
• fluoride dental treatment for children under four years
of age;
•
•
•
•
•
•
•
excision of xanthelasma;
circumcision of newborns;
hypnotherapy;
medical examination for drivers;
alcohol/drug treatment outside Canada;
consultation required by hospital regulation;
therapeutic abortions performed in the province at a
facility not approved by the College of Physicians and
Surgeons of Newfoundland and Labrador;
• sex reassignment surgery, when not recommended by
the Clarke Institute of Psychiatry;
• in vitro fertilization and OSST (ovarian stimulation
and sperm transfer);
Canada Health Act — Annual Report 2011–2012
21
Chapter 3: Newfoundland and Labrador
• reversal of previous sterilization procedure;
• surgical, diagnostic or therapeutic procedures provided
in 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.
The majority of diagnostic services (e.g., laboratory services and
x-ray) are performed within public facilities in the province.
Hospital policy concerning access ensures that third parties are
not given priority access.
Medical goods and services that are implanted and associated
with an insured service are provided free of charge to the patient
and are consistent with national standards of practice. Patients
retain the right to financially upgrade standard medical goods
or services. Standards for medical goods are developed by the
hospitals providing those services in consultation with service
providers.
The Medical Care Insurance Act, 1999 provides the LieutenantGovernor in Council with the authority to make regulations
prescribing which services are or are not insured services for
the purpose of the Act.
3.0UNIVERSALITY
3.1Eligibility
There were 527,714 people registered with the program as of
March 31, 2012. 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. 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
22
not meet the established criteria; tourists, transients, visitors
and their dependants; Canadian Forces and Royal Canadian
Mounted Police (RCMP) personnel; inmates of federal prisons; and armed forces personnel from other countries who
are stationed in the province. If the status of these individuals
changes, they must meet the criteria for eligibility as noted
above in order to become eligible.
3.2 Other Categories of Individual
Foreign workers, international students, clergy and dependants
of North Atlantic Treaty Organization (NATO) personnel are
eligible for benefits. Holders of Minister’s permits are also
eligible, subject to MCP approval.
4.0PORTABILITY
4.1 Minimum Waiting Period
Insured persons moving to Newfoundland and Labrador from
other provinces or territories are entitled to coverage on the
first day of the third month following the month of arrival.
Persons arriving from outside Canada to establish residence
are entitled to coverage on the day of arrival. The same applies
to discharged members of the Canadian Forces and the
RCMP, 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
Canada Health Act — Annual Report 2011–2012
Chapter 3: Newfoundland and Labrador
and out-patient services are payable based on national rates
agreed to by provincial and territorial health plans through
the Interprovincial Health Insurance Agreements Coordinating
Committee.
Medical services incurred in all provinces (except Quebec)
or territories, are paid through the Medical Reciprocal Billing
Agreement at host province or territory rates. Claims for
medical services received in Quebec are submitted by the
patient to the MCP for payment at host province rates.
In order to qualify for out-of-province coverage, a beneficiary
must comply with the legislation and MCP rules regarding
residency in Newfoundland and Labrador. A resident must
reside in the province at least four consecutive months in
each 12-month period to qualify as a beneficiary. Generally,
the rules regarding medical and hospital care coverage during
absences include the following:
• Before leaving the province for extended periods, a 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.
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 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.
• Persons leaving the province for employment purposes
4.4 Prior Approval Requirement
• Persons must not establish residence in another province,
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.
may receive a certificate for coverage up to 12 months.
Verification of employment may be required.
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.
Canada Health Act — Annual Report 2011–2012
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.
23
Chapter 3: Newfoundland and Labrador
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
Access to insured health services in Newfoundland and
Labrador is provided on uniform terms and conditions.
There are no co-insurance charges for insured hospital
services and there is no extra-billing by physicians in the
province.
The Department of Health and Community Services works
closely with educational institutions within the province to
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.
In 2011–2012, a record investment of $2.9 billion was
allocated for health operations, which signifies an increase
of more than 7.4 percent over the previous year’s $2.7 billion. This included investments in health care infrastructure
totaling $272.2 million; investments for new construction
and redevelopment totaling $200.6 million, $21.6 million
for repairs and renovations and $50.0 million to purchase
new medical equipment.
In 2011–2012, the Department of Health and Community
Services established an Access and Clinical Efficiency Division
to provide provincial leadership and oversight on the issues of
reducing wait times and improving efficiency for key services in
the province’s health care system, and to continue monitoring
and publicly reporting wait times for the national benchmarks
established in 2005.
Through the work of this division, two five-year (2012–2017)
provincial wait time reduction strategies were announced in
February 2012:
The first, A Strategy to Reduce Wait Times for Hip and Knee
Joint Replacement in Newfoundland and Labrador will focus
on: shortening the wait time and improving coordination of the
initial orthopedic assessment (Wait 1) and the services required
by patients before and after hip and knee joint replacement
surgeries are performed; improving the efficiency of hospital
services associated with providing hip and knee joint replacement surgeries; reducing the backlog of patients waiting for
joint replacement surgery; improving the collection and use
of wait time data for joint replacement surgeries; and reducing
the number of patients who require joint replacement in the
longer term.
24
The second, A Strategy to Reduce Emergency Department
Wait Times in Newfoundland and Labrador will focus on:
improving the efficiency of high volume emergency departments; improving access to community-based health services
that will support effective utilization of emergency departments; implementing a province-wide standard for patient
triage and wait times to receive initial medical attention;
improving the collection, reporting and use of emergency
department wait time data; and, improving communication
with patients and the public regarding emergency department
wait times.
Provincial wait time data for the period ending March 31, 2012,
shows that on average 88 per cent of residents of Newfoundland
and Labrador received access to the priority benchmark services
within the recommended time frames during the fourth quarter
of 2011–2012 (January 1 to March 31). Almost 100 per cent of
patients requiring radiation treatment for cancer continue to
receive access within the benchmark of 28 days. Benchmark
results show that 100 per cent of cardiac bypass patients continue
to receive surgery more quickly than the recommended targets.
Over 80 per cent of patients underwent cataract procedures
within 112 days. Wait time results for hip replacement surgeries remained above 80 per cent within 182 days, while knee
replacement surgeries increased to almost 80 per cent within
182 days. Also, 90 per cent of residents underwent surgery to
repair a fractured hip within the benchmark of 48 hours.
In keeping with the Department Health and Community
Service’s strategic plan, wait times for select cancer surgery
and endoscopy services will start to be publicly reported
on the website in 2012–2013.
5.2 Physician Compensation
The legislation governing payments to physicians and dentists for insured services is the Medical Care Insurance Act,
1999. The current methods of remuneration to compensate
physicians for providing insured health services include feefor-service, salary, contract, and sessional block funding.
Compensation agreements are negotiated between the
provincial government and the Newfoundland and Labrador
Medical Association (NLMA), on behalf of all physicians.
Representatives from the RHAs play a role in this process.
A new Memorandum of Agreement was reached with the
NLMA in December 2010, which increases overall physician
compensation by approximately 26 percent. The Agreement
expires on September 30, 2013. Physicians are paid via feefor-service, salary or alternate payment plan (APP) with an
increasing interest in APPs as a method of remuneration.
Canada Health Act — Annual Report 2011–2012
Chapter 3: Newfoundland and Labrador
5.3 Payments to Hospitals
The Department is responsible for funding RHAs for ongoing operations and capital acquisitions. Funding for insured
services is provided to the RHAs as an annual global budget.
Payments are made in accordance with the Hospital Insurance
Agreement Act and the Regional Health Authorities Act. As
part of their accountability to the government, the health
authorities are required to meet the Department’s annual
reporting requirements, which include audited financial
statements and other financial and statistical information.
The global budgeting process devolves the budget allocation
authority, responsibility, and accountability to all appointed
boards in the discharge of their mandates.
Throughout the fiscal year, the RHAs forwarded additional
funding requests to the Department for any changes in program areas or increased workload volume. These requests were
reviewed and, when approved by the Department, funded
at the end of each fiscal year. Any adjustments to the annual
funding level, such as for additional approved positions or
program changes, were funded based on the implementation
date of such increases and the cash flow requirements.
Canada Health Act — Annual Report 2011–2012
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 2011–2012,
these documents include:
• the 2011–2012 Public Accounts;
• the Estimates 2011–2012; and
• the Budget Speech 2011.
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 (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
506,530
514,470
523,433
523,508
527,714
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 ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
50
51
51
51
51
798,018,159
880,628,613
964,078,687
1,028,697,016
1,088,392,487
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
1
1
1
1
1
307,825
389,375
432,500
660,625
697,375
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
1,910
1,732
1,595
1,632
1,648
16,509,144
15,695,411
16,928,930
21,096,749
17,507,684
34,159
29,758
25,770
23,156
23,482
6,817,250
7,680,172
7,325,977
7,214,089
7,216,918
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
26
73
90
94
97
126
496,719
368,959
123,890
318,203
224,822
404
400
317
445
475
651,841
204,973
272,567
209,257
91,089
Canada Health Act — Annual Report 2011–2012
Chapter 3: Newfoundland and Labrador
Insured Physician Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
989
1,037
1,075
1,096
1,115
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
not available
not available
not available
not available
not available
189,169,000
199,127,000
211,145,000
216,931,000
218,561,000
14.Number of participating physicians (#).1
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
168,000
136,000
147,000
155,000
154,000
6,320,000
6,161,000
6,991,000
6,665,000
6,627,000
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
2,300
2,900
3,100
3,600
3,400
300,000
240,000
157,000
202,000
237,000
Insured Surgical-Dental Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
25
25
31
29
25
885
2,995
290
1,093
2,222
73,000
331,000
28,000
158,000
329,000
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
1.
Excludes inactive physicians.Total salaried and fee-for-service.
Canada Health Act — Annual Report 2011–2012
27
28
Canada Health Act — Annual Report 2011–2012
Chapter 3: Prince Edward Island
Health Services Payment Act (1988). Together, the Plans insure
services as defined under section 2 of the Canada Health Act.
The Department of Health and Wellness is responsible for
providing policy, strategic and fiscal leadership for the healthcare
system, while Health PEI is responsible for service delivery and
the operation of hospitals, health centres, manors and mental
health facilities. Health PEI is responsible for the hiring of
physicians, while the Public Service Commission of PEI hires
nurse practitioners, nurses and all other health related workers.
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
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 the province 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 August 2011. Public
Accounts Volume II Operating Fund Financial Statements,
Details of Revenues and Expenditures, Financial Statements
of Agencies and Crown Corporations was published in
November 2011.
• perform such other duties as the Minister may direct.
The provincial Auditor General, through the Audit Act, has
the discretionary authority to conduct further audit reviews
on a comprehensive or program specific basis.
1.0 Public Administration
2.0Comprehensiveness
1.1 Health Care Insurance Plan and
Public Authority
2.1 Insured Hospital Services
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
Canada Health Act — Annual Report 2011–2012
Insured hospital services are provided under the Hospital and
Diagnostic Services Insurance Act (1988). The accompanying
Regulations (1996) define the insured in- and out-patient
hospital services available at no charge to a person who is
eligible. Insured hospital services include: necessary nursing
services; laboratory, radiological and other diagnostic procedures; accommodations and meals at a standard ward
29
Chapter 3: Prince Edward Island
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, 2012 was 232.
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, 2012, no physicians had opted out of the
Medical Services Insurance Plan.
Any basic health services rendered by physicians that are
medically required are covered by the Medical Services
Insurance Plan. These include most physicians’ services in
the office, at the hospital or in the patient’s home; medically
necessary surgical services, including the services of anaesthetists and surgical assistants where necessary; obstetrical
services, including pre- and post-natal care, newborn care
30
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 2011–2012
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 2011-2012 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 2011–2012
3.0 Universality
3.1Eligibility
The Health Services Payment Act and regulations, section 3,
define eligibility for the Medical Services Insurance Plan.
This Plan is designed to provide coverage for eligible Prince
Edward Island residents. A resident is anyone legally entitled
to remain in Canada and who makes his or her home and is
ordinarily present on an annual basis for at least six months
plus a day, in Prince Edward Island.
All new residents must register with the Department in order
to become eligible. Persons who establish permanent residence in Prince Edward Island from elsewhere in Canada
will become eligible for insured hospital and medical services
on the first day of the third month following the month of
arrival.
Residents who are ineligible for insured hospital and medical services coverage in Prince Edward Island are those
who are eligible for certain services under other federal or
provincial government programs, such as members of the
Canadian Forces, inmates of federal penitentiaries, Workers’
Compensation or Veterans Affairs Canada.
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.
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.
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, 2012,
was 147,942.
31
Chapter 3: Prince Edward Island
Foreign students, temporary workers, refugees and Minister’s
Permit holders are not eligible for hospital and medical insurance
benefits.
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.
4.0Portability
4.4 Prior Approval Requirement
4.1 Minimum Waiting Period
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.
3.2 Other Categories of Individual
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
The Health Services Payment Act is the enabling legislation
that defines portability of health insurance during temporary
absences outside Canada, as allowed under section 5(1)(e).
Insured residents may be temporarily out of the country
for a 12 month period one time only. Students attending
a recognized learning institution in another country must
provide proof of enrolment from the educational institution
on an annual basis. Students must notify the Registration
Department upon returning from outside the country.
For Prince Edward Island residents leaving the country for
work purposes for longer than one year, coverage ends the
day the person leaves.
32
5.0Accessibility
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 2011–2012
fiscal year include:
• Following a successful two year pilot, Prince Edward
Island announced the implementation of the Colorectal
Cancer Screening Program this year. This program
provides access to simple-to-use, home-based tests for
all Islanders between ages 50 and 74.
• A major expansion of haemodialysis services in Prince
Edward Island was undertaken this year. This will result in
increased capacity of over 125 percent for haemodialysis
services once these new facilities are completed.
• A major multi-year redevelopment project at our provincial referral hospital is well underway with construction
nearing completion on the Ambulatory Care Centre at the
Queen Elizabeth Hospital.
Canada Health Act — Annual Report 2011–2012
Chapter 3: Prince Edward Island
• This past year has also seen major investment as part of
a long-term care manor replacement strategy. While two
new manors held open houses, construction also began on
another two new manors in different geographic regions
of the province.
• The PEI Family Medicine Residency Program saw its first
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.
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.
5.2 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
Canada Health Act — Annual Report 2011–2012
some physicians receive salary, contract and sessional payments. Alternate payment modalities are growing and seem
to be the preference for new graduates. Currently, 67 percent
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.
5.3 Payments to Hospitals
Payments (advances) to provincial hospitals and community
hospitals for hospital services are approved for disbursement
by the Department in line with cash requirements and are
subject to approved budget levels.
The usual funding method includes using a global budget
adjusted annually to take into consideration increased costs
related to such items as labour agreements, drugs, medical
supplies and facility operations.
6.0 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 2011–2012 Annual Budget and in the 2011–2012 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 2011–2012
Annual Report.
33
Chapter 3: Prince Edward Island
Registered Persons
1. Number as of March 31st (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
146,518
142,305
143,238
146,049
147,942
Insured Hospital Services Within Own Province or Territory
Public Facilities
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
7
7
7
7
7
137,982,600
151,304,500
161,439,600
172,100,500
183,647,900
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4. Number of private for-profit facilities
providing insured health services (#).
0
0
0
0
0
5. Payments to private for-profit facilities
for insured health services ($).
0
0
0
0
0
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
2,253
2,591
2,692
2,564
2,509
19,448,899
20,582,454
26,099,326
25,159,408
23,821,199
17,867
18,488
17,147
16,763
15,391
4,292,114
5,290,630
5,385,508
5,286,499
5,136,948
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
28
34
46
29
43
49,616
113,901
157,547
70,768
164,610
137
122
127
113
165
27,533
33,919
65,114
44,213
58,796
Canada Health Act — Annual Report 2011–2012
Chapter 3: Prince Edward Island
Insured Physician Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
221
256
240
242
232
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
14.Number of participating physicians (#).1
17. Total payments for services provided
by physicians paid through all payment
methods ($).
61,974,581
18.Total payments for services provided by
physicians paid through fee-for-service ($).
34,973,359
2
61,445,780
41,123,808
2
72,874,951
2
45,959,450
62,670,303
2
49,332,788
60,719,582
2
50,264,859
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
77,992
77,830
79,139
80,559
83,086
6,035,626
5,998,751
6,386,325
6,247,907
6,330,440
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
562
1,053
786
684
950
23,979
52,601
39,137
31,729
40,600
Insured Surgical-Dental Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
3
3
3
2
2
364
424
451
352
377
95,749
149,794
171,901
137,566
125,392
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
7. Total does not include locums or visiting specialists.
8. Reflects payments made through claim submissions and salary allocations.
Canada Health Act — Annual Report 2011–2012
35
36
Canada Health Act — Annual Report 2011–2012
Chapter 3: NOVA SCOTIA
basket of publicly insured services to include home care, long
term care, and enhanced pharmaceutical coverage. Nova
Scotia also has much higher than average rates of chronic
diseases such as cancers and diabetes which contribute to
the rising costs of health care delivery.
Despite these ever increasing pressures and challenges,
Nova Scotia continues to be committed to the delivery of
medically necessary services consistent with the principles
of the Canada Health Act.
Nova Scotia
Introduction
The Nova Scotia Department of Health and Wellness mission
is, “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 communitybased 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 thirty-seven 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
separate board, administrative and service delivery structures.
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 (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 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 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.
The Department of Health and Wellness and Medavie
Blue Cross entered into a service level agreement, effective
August 1, 2005. Under the agreement, Medavie Blue Cross
is responsible for operating and administering programs
contained under MSI, Pharmacare Programs and Health
Card Registration Services.
Nova Scotia faces a number of challenges in the delivery of health
care services. Nova Scotia’s population is aging. Approximately
16.0% of the Nova Scotian population is sixty-five or over and
this figure is expected to reach 24.3% by 2026. In response to
the needs of the aging population, Nova Scotia has expanded its
In the service level agreement, Medavie Blue Cross 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 is audited every year on
various areas of reporting.
Canada Health Act — Annual Report 2011–2012
1.2 Reporting Relationship
37
Chapter 3: NOVA SCOTIA
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
provides audited financial statements of Medical Services
Insurance (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.
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 Care 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 Care receives written authorization
from the Department of Health and Wellness for the physicians to whom it may 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.
All MSI and Pharmacare transactions are subject to a review
by the Office of the Auditor General.
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, Quikcard Solutions Incorporated 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;
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.
• use of radiotherapy and physiotherapy services for
A report management schedule, developed between Medavie
Blue Cross and the Department of Health and Wellness,
outlines 95 required reports submitted to the Department
at various points throughout the fiscal year. Reports pertain to medicare enrollment and monitoring, billing claims,
provider management, audit and program utilization. These
reports are submitted on a monthly, quarterly, or annual basis,
and are intended to cover the previous reporting period.
• laboratory and radiological examinations;
• diagnostic procedures involving the use of
38
in-patients, where available; and
• blood or therapeutic blood fractions.
Out-patient services include:
radio-pharmaceuticals;
• electroencephalographic examinations;
• use of occupational and physiotherapy facilities,
where available;
Canada Health Act — Annual Report 2011–2012
Chapter 3: NOVA SCOTIA
•
•
•
•
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 Proposal1 to the
Department of Health and Wellness. 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. 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, 2012, 2,473 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, 2012, 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 2011–2012. 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/ Doctors Nova
Scotia (DHW/DHA/DNS) 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 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 2011–2012, 28 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
Acute & Tertiary Care Branch as required by Insured Dental
Services Tariff Regulations. 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
maxillary facial 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
1. Emergency/unexpected requirements may be considered at any time throughout the fiscal year.
Canada Health Act — Annual Report 2011–2012
39
Chapter 3: NOVA SCOTIA
Health and Wellness, in consultation with specific experts in
the field, renders the decision as to whether or not the new
procedure becomes an insured service.
“Other extraction services” (routine extractions) at public
expense were 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 he/she has indicated in writing in the
patient’s medical treatment plan that the routine dental
extractions are required prior to performing the medical
treatment/procedure.
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital services include:
•
•
•
•
preferred accommodation at the patient’s request;
•
•
•
•
•
•
cosmetic surgery;
telephones;
televisions;
drugs and biologicals ordered after discharge from
hospital;
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.
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 or telephone renewal of prescriptions;
• examinations required by third parties;
• group immunizations or inoculations unless approved by
the Department;
• preparation of certificates or reports;
• testimony in court;
• services in connection with an electrocardiogram, electro-
myogram 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, Department of National Defence, and the
Royal Canadian Mounted Police.
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/
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 province
provides alternatives to any of the enhanced goods and
services.
The Department of Health and Wellness also 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.
2. These services may be insured when approved as special consideration for medical reasons only.
40
Canada Health Act — Annual Report 2011–2012
Chapter 3: NOVA SCOTIA
3.0 Universality
3.2 Other Categories of Individuals
3.1 Eligibility
The following persons may also be eligible for insured health
care services in Nova Scotia once they meet the specific
eligibility criteria for their situations:
Eligibility for insured health care services in Nova Scotia is
outlined under section 2 of the Hospital Insurance Regulations
made pursuant to section 17 of the Health Services and Insurance
Act. All residents of Nova Scotia are eligible. A resident is defined
as anyone who is legally entitled to stay in Canada and who
makes his or her home and is ordinarily present in Nova Scotia.
A person is considered to be “ordinarily present” in Nova
Scotia if the person:
• makes his or her permanent home in Nova Scotia;
• is physically present in Nova Scotia for at least 183 days
in any calendar year (short term absences under 30 days,
within Canada, are not monitored); and
• is a Canadian citizen or “Permanent Resident” as defined
by Citizenship and Immigration Canada.
Persons moving to Nova Scotia from another Canadian
province will normally be eligible for 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
2011–2012.
In 2011–2012, the total number of residents registered with
the health insurance plan was 994,018.
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/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 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 2011–2012, there were 32,610 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, providing 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 him/her or their
dependents.
In 2011–2012, there were 3,422 individuals with Employment
Authorizations covered under the health care insurance plan.
Canada Health Act — Annual Report 2011–2012
41
Chapter 3: NOVA SCOTIA
Study Permits: Persons moving to Nova Scotia from another
country and who possess a Study Permit will be eligible for
MSI on the first day of the thirteenth month following the
month of their arrival, provided they have not been absent
from Nova Scotia for more than 31 consecutive days, 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 2011–2012, there were 1,362 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.
4.0Portability
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 full-time
attendance at an educational institution, may remain eligible
for MSI on a yearly basis. To qualify for MSI, the student must
provide to MSI a letter directly from the educational institution which states that they are registered as 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, territory or
country. 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.
42
Québec is the only province that does not participate in the
medical reciprocal 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. The total
amount paid by the plan in 2011–2012 for in-patient and
out-patient hospital services received in other provinces and
territories was $31,793,582.
Nova Scotia pays the host province rates for insured services
in all reciprocal billing situations.
There were no changes made in Nova Scotia in 2011–2012
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 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 educational
institution outside Canada may remain eligible for MSI on a
yearly basis. To qualify for MSI, the student must provide to
MSI a letter obtained from the educational institution that
verifies the student’s attendance there in each year for which
MSI coverage is requested.
Persons who engage in employment (including volunteer/
missionary work/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 2011–2012
regarding out-of-Canada portability. The total amount spent
in 2011–2012 for insured in-patient services provided outside of Canada was $2,176,921. Nova Scotia does not cover
out-patient services out-of-country.
Canada Health Act — Annual Report 2011–2012
Chapter 3: NOVA SCOTIA
4.4 Prior Approval Requirement
Prior approval must be obtained for elective services outside the
country. Application for prior approval is made to the Medical
Director of the MSI Plan by a specialist in Nova Scotia on
behalf of an insured resident. The medical consultant reviews
the terms and conditions and determines whether or not the
service is available in the province, or if it can be provided in
another province or only out-of-country. The decision of the
medical consultant is relayed to the patient’s referring specialist.
If approval is given to obtain service outside the country, the full
cost of that service will be covered under MSI.
5.0Accessibility
5.1 Access to Insured Health Services
Section 3 of the Health Services and Insurance Act states
that subject to this Act and the regulations, all residents of
the province are entitled to receive insured hospital services
from hospitals on uniform terms and conditions. As well, all
residents of the province are insured on uniform terms and
conditions in respect of the payment of insured professional
services to the extent of the established tariff. There are no
user charges or extra charges allowed under the plan.
Nova Scotia continually reviews access situations across
Canada to ensure equity of access. In areas where improvement is deemed necessary, depending on the province’s
financial situation, extra funding is generally allocated to
that need.
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, streamlined patient-centred emergency care, better care for seniors,
people with mental illness and other patients with complex
needs, greater awareness of emergency telephone number
(911) and the HealthLink 811 and funding 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, 5 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. The Department has worked with system
partners to address several other areas of health care access.
This has included opening a new Rapid Assessment Unit, the
addition of 8 new hospital beds for Capital District Health
Authority, and the establishment of stroke units across the
province in regional hospitals.
Canada Health Act — Annual Report 2011–2012
Nova Scotia will also be expanding pre-habilitation orthopedic
services to three more sites in the province, and expansion of
full-field mammography at eleven fixed sites.
Access to Insured Physician and Surgical-Dental 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 increased the capacity for medical education
for both Canadian medical students and internationally educated physicians, coordinates ongoing recruitment activities,
and has provided funding to create a re-entry program for
general practitioners wishing to enter specialty training
after completing two years of general practice service in
the province.
5.2 Physician Compensation
The Health Services and Insurance Act, RS Chapter 197 governs payment to physicians and dentists for insured services.
Physician payments are made in accordance with a negotiated agreement between Doctors Nova Scotia and the
Nova Scotia Department of Health and Wellness. Doctors
Nova Scotia is recognized as the sole bargaining agent in
support of physicians in the province. When negotiations
take place, representatives from Doctors Nova Scotia and
the Department of Health and Wellness negotiate the total
funding and other terms and conditions. The agreement lays
out what the medical services unit value will be for physician
services and addresses other issues such as the Canadian
Medical Protective Association, membership benefits, emergency department 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 payment
for physician services. However, there has been significant
growth in the number of alternative payment arrangements
in place in Nova Scotia. In the 1997–1998 fiscal year, about
9 percent of doctors were paid solely through alternative
funding. In 2011–2012, approximately 23 percent of physicians were remunerated exclusively through alternative
funding. Approximately 64 percent of physicians in Nova
Scotia receive all or a portion of their remuneration through
alternative funding mechanisms.
43
Chapter 3: NOVA SCOTIA
Alternative funding plans can be broken down into
three groups:
1) Academic Funding Plan (these physicians are mainly
located in Halifax at the Queen Elizabeth II Health
Sciences Centre (QEII) and the IWK Health Centre
(IWK)) — Most of the Academic Specialist groups are
on academic funding arrangements with the exception
of Urology, QEII and IWK Radiology, IWK Obstetrics
& Gynaecology, Ophthalmology and Nephrology.
2) Currently there are regional specialist contracts for
anaesthesiology, geriatrics, neonatology, paediatrics,
obstetrics/gynaecology, and palliative care.
3) There are also contract arrangements available to
general practitioners in certain rural areas and general
practitioner/nurse practitioner contracts that support
collaborative practice teams in designated areas.
Payment rates for dental services in the province are negotiated
between the Department of Health and Wellness and the Nova
Scotia Dental Association, and follow a process similar to physician negotiations. Dentists are paid on a fee-for-service basis.
Negotiations are underway for renewal of these services.
5.3 Payments to Hospitals
The Department of Health and Wellness establishes budget
targets for health care services. It does this by receiving business plans from the nine district health authorities (DHAs),
the IWK Health Centre and other non-DHA organizations.
Approved provincial estimates form the basis on which payments are made to these organizations for service delivery.
The Health Authorities Act was given Royal Assent on
June 8, 2000. The Act instituted the nine DHAs and the
IWK that replaced the former regional health boards.
44
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.
In 2011–2012, 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 $1.59 billion.
6.0 Recognition Given to
Federal Transfers
In Nova Scotia, the Health Services and Insurance Act
acknowledges the federal contribution regarding the cost
of insured hospital services and insured health services
provided to provincial residents. The residents of Nova Scotia
are aware of ongoing federal contributions to Nova Scotia
health care through the Canada Health Transfer (CHT)
as well as other federal funds through press releases and
media coverage.
The Government of Nova Scotia also recognized the federal
contribution under the CHT in various published documents,
including the following documents:
• Public Accounts 2011–2012 released September 30, 2012; and
• Budget Estimates and Supplementary Detail 2011–2012
released April 3, 2012.
Canada Health Act — Annual Report 2011–2012
Chapter 3: NOVA SCOTIA
Registered Persons
1. Number as of March 31st (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
970,450
975,206
981,922
988,585
994,018
Insured Hospital Services Within Own Province or Territory
Public Facilities
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
35
35
35
35
35
1,367,828,540
1,406,145,241
1,531,561,311
1,560,236,537
1,593,552,159
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
0
0
0
0
0
not available
not available
not applicable
not applicable
not applicable
2. Number (#).
3. Payments for insured health services ($). 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 ($).
4
Insured Hospital Services Provided to residents in another province or territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
2,257
2,310
2,089
1,946
2,402
16,726,553
15,924,363
16,289,798
13,614,172
19,417,809
42,569
42,089
39,443
38,261
36,125
8,946,688
11,558,634
11,180,204
10,978,035
12,375,773
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
not available
not available
not available
not available
not applicable
1,257,620
1,190,016
1,286,181
788,368
2,176,921
12.Total number of claims, out-patient (#).
not available
not available
not available
not available
not applicable
13.Total payments, out-patient ($).
not available
not available
not available
not available
not applicable
11. Total payments, in-patient ($).
3. This reflects payments made to the public facilities noted under indicator 2 above.
4. 2009–2010 includes payments to the DHAs for Care Coordination as program was integrated with the DHAs in the fiscal year.
5. Scotia Surgery is not considered private; it is classified as a hospital (funded by the Department of Health).
Canada Health Act — Annual Report 2011–2012
45
Chapter 3: NOVA SCOTIA
Insured Physician Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
2,290
2,343
2,401
2,434
2,473
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
17. Total payments for services provided
by physicians paid through all payment
methods ($).
555,659,788
598,546,450
637,434,810
661,968,168
681,963,292
18.Total payments for services provided by
physicians paid through fee-for-service ($).
258,751,069
266,174,648
301,217,024
301,629,014
309,391,089
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of non-participating physicians (#).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
212,404
215,490
197,580
195,538
211,030
7,606,977
7,671,840
7,362,277
7,426,414
8,297,188
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
2,701
3,051
3,418
3,092
3,295
134,729
161,555
200,452
169,312
185,142
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).6
25.Total payments ($).7
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
27
29
55
26
28
5,831
6,254
6,536
6,913
7,228
1,215,333
1,374,645
1,380,344
1,459,608
1,338,592
6. Total services includes block funded dentists.
7.
Total payments does not include block funded dentists.
46
Canada Health Act — Annual Report 2011–2012
Chapter 3: NEW BRUNSWICK
1.2 Reporting Relationship
The Medicare—Insured Services Branch and the Medicare—
Eligibility and Claims Branch of the Department are mandated
to administer the Medical Services Plan. The Minister reports
to the Legislative Assembly through the Department’s annual
report and through regular legislative processes.
New Brunswick
Introduction
Through effective leadership and partnership, New Brunswick’s
health care system worked towards being more effective, adaptable and accountable within tight financial constraints, while
continuing to provide excellent and trusted care to the public
it served during 2011–2012.
New Brunswick remained committed to the five fundamental
principles of the Canada Health Act (CHA), a commitment
which was evident both in the day to day functioning of the
various elements of New Brunswick’s health system, and in
new initiatives announced or implemented in 2011–2012.
For information about the Ministry’s 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 2011–2012
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
Three 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. Medicare also 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.
2.0Comprehensiveness
2.1 Insured Hospital Services
Legislation providing for insured hospital services includes the
Hospital Services Act, section 9 of Regulation 84-167, and the
Hospital Act. Under Regulation 84-167 of the Hospital Services
Act, New Brunswick residents are entitled to the following
insured 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.
47
Chapter 3: NEW BRUNSWICK
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/treat any injury, illness or
disability, excluding those related to the provision of drugs or
third party diagnostic requests.
2.2 Insured Physician Services
The Medical Services Payment Act and corresponding regulations
provide for insured physician services. As of March 31, 2012
there were 1618 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.
The services entitled under Medicare include:
a) the medical portion of all services rendered by medical
practitioners that are medically required and;
b) certain surgical-dental procedures when performed by a
physician or a dental surgeon in a hospital facility.
An individual, 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 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.
48
13 new service codes were added during this reporting period.
•
•
•
•
•
•
•
•
•
Laparoscopic Nephroureterectomy,
•
•
•
•
Insertion of Wall Stents including scope,
Laparoscopic Pyeloplasty,
Laparoscopic Nephrectomy,
Laparoscopic Radical Nephrectomy,
Laparoscopic Nephrectomy—etopic,
CT Angiography—other than coronary,
Pharmacologic Stress Test—solo procedure,
Sentinel Node Biopsy,
Sentinel Node Biopsy, in conjunction with another
procedure—add-on,
Laparoscopic Nissen Fundoplication,
Chronic Disease Management—COPD, and
Needle Aponeurotomy.
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/
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, 2012, there were 104 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.
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;
Canada Health Act — Annual Report 2011–2012
Chapter 3: NEW BRUNSWICK
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
purposes;
•
•
•
•
• 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;
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;
• 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;
Canada Health Act — Annual Report 2011–2012
• 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 performed
as a stand-alone procedure in a facility that is not an
approved hospital facility.
Dental services not specifically listed in Schedule 4 of the
Dental Schedule are not covered by the Plan. Those listed in
Schedule 2 are considered the only non-insured medical services. There are no specific policies or guidelines, other than
the Act and regulations, to ensure that charges for uninsured
medical goods and services (i.e., fibreglass 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 service plans across
the country, and the previous use of the particular service.
49
Chapter 3: NEW BRUNSWICK
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 2011–2012, no services were removed from the insured
service list.
3.0Universality
3.1Eligibility
Sections 3 and 4 of the Medical Services Payment Act
and Regulation 84-20 define eligibility for the health
care insurance plan in New Brunswick.
Residents are required to complete a Medicare application
and 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, 2012, there were
748,406 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) In June 2010, Regulation 84-20 under the Medical Services
Payment Act was amended to state that dependents of
Canadian Armed Forces personnel or their spouses moving from within Canada to New Brunswick will now be
entitled to first day coverage under the program, provided
they are deemed to have established permanent residence
in New Brunswick.
b) In June 2010, Regulation 84-20 under the Medical Services
Payment Act was amended to state that immigrants or
Canadian residents moving or returning to New Brunswick
will now be 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;
• 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).
Provisions to become eligible for Medicare coverage include:
• Non-Canadians who are issued an immigration permit that
would not normally entitle them to coverage are eligible if
legally married to, or in a common-law relationship with, a
New Brunswick resident.
Provisions when status changes include:
• Persons who are discharged or released from the Canadian
Armed Forces, the RCMP or a federal penitentiary. Provided
they are residing in New Brunswick when discharged/
released, these persons become eligible for coverage on
the date of their discharge/release. An application must
be completed, and the official date of release and proof
of citizenship must be provided.
3.2 Other Categories of Individual
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.
Canada Health Act — Annual Report 2011–2012
Chapter 3: NEW BRUNSWICK
4.0Portability
4.1 Minimum Waiting Period
A person is eligible for New Brunswick Medicare coverage on
the first day of the third month following the month permanent residence has been established. The three month waiting
period is legislated under New Brunswick’s Medical Services
Payment Act.
4.2 Coverage During Temporary Absences
in Canada
The legislation that defines portability of health insurance
during temporary absences in Canada is the Medical Services
Payment Act, Regulation 84-20, sub-sections 3(4) and 3(5).
Medicare coverage is extended 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.
Canada Health Act — Annual Report 2011–2012
New Brunswick has formal agreements for reciprocal billing
arrangements of insured hospital services with all provinces
and territories. In addition, New Brunswick has reciprocal agreements with all provinces, except Quebec, for the
provision of insured physician services. Services provided by
Quebec physicians to New Brunswick residents are paid at
Quebec rates provided the service delivered is insured in New
Brunswick. The majority of such claims are received directly
from Quebec physicians. Any claims submitted directly by a
patient are reimbursed to the patient.
4.3 Coverage During Temporary Absences
Outside Canada
The legislation that defines portability of health insurance
during temporary absences outside Canada is the Medical
Services Payment Act, Regulation 84-20, subsections 3(4)
and 3(5).
Eligibility for “temporarily absent” New Brunswick residents is
determined in accordance with the Medical Services Payment
Act and regulations and the Interprovincial Agreement on
Eligibility and Portability.
Residents temporarily employed outside Canada are granted
coverage for 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 be subject to the
legislated three month waiting period. 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.
51
Chapter 3: NEW BRUNSWICK
Mobile Workers
4.4 Prior Approval Requirement
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:
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.
• 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
• 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 out-of-country
must supply the following information and documentation:
• a letter of request from the New Brunswick resident with
their signature, detailing their absence, 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 retain
eligibility;
• permanent residence is not established outside
New Brunswick; and
• health coverage is not received elsewhere.
52
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;
• 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.
The following are considered exemptions under the out-ofcountry coverage policy:
• haemodialysis: patients will be required to obtain prior
approval and Medicare will reimburse the resident at a
rate equivalent to the inter-provincial rate of $472 per
session; and
• allergy testing for environmental sensitivity: all tests
outside the country will be paid at a maximum rate of
$50 per day, an amount equivalent to an out-patient visit.
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.
Canada Health Act — Annual Report 2011–2012
Chapter 3: NEW BRUNSWICK
5.0Accessibility
5.1 Access to Insured Health Services
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.
Access in a resident’s official language of choice is not a limiting
factor, regardless of where a resident receives services in the
province.
5.2 Physician Compensation
Payments to physicians and dentists are governed under the
Medical Services Payment Act, Regulations 84-20, 93-143 and
2002-53.
The methods used to compensate physicians for providing
insured health services in New Brunswick are fee-for-service,
salary and sessional or alternate payment mechanisms that
may also include a blended system.
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.
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.
Any requests for funding for new programs/services are
submitted to the Deputy Minister of Health for approval.
Funding for approved new programs/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.
5.3 Payments to Hospitals
6.0 Recognition Given to
Federal Transfers
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.
New Brunswick routinely recognizes the federal role regarding
its contributions under the Canada Health Transfer in public
documentation presented through legislative and administrative processes. Federal transfers are identified in the Main
Estimates document and in the Public Accounts of New
Brunswick. Both documents are published annually by the
New Brunswick government.
Canada Health Act — Annual Report 2011–2012
53
Chapter 3: NEW BRUNSWICK
Registered Persons
1. Number as of March 31st (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
740,845
742,974
744,048
748,352
748,406
Insured Hospital Services Within Own Province or Territory
Public Facilities
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
50
53
56
57
56
1,372,911,800
1,449,216,237
1,590,399,994
1,616,340,008
1,721,356,342
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4. Number of private for-profit facilities
providing insured health services (#).1
0
0
0
0
0
5. Payments to private for-profit facilities
for insured health services ($).1
0
0
0
0
0
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4,363
3,919
4,036
4,537
3,925
42,267,067
37,772,992
37,343,696
44,337,432
38,410,486
51,406
46,824
49,005
44,444
32,310
11,316,103
12,858,195
14,912,717
14,186,848
11,455,683
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
209
196
251
245
242
726,650
753,104
556,678
607,147
808,783
1,073
1,430
1,575
1,805
1,285
441,575
561,855
883,980
798,355
857,130
1. There are no private for-profit facilities operating in New Brunswick.
54
Canada Health Act — Annual Report 2011–2012
Chapter 3: NEW BRUNSWICK
Insured Physician Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
1,453
1,500
1,571
1,588
1,618
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
421,547,901
441,197,899
505,899,089
538,111,685
543,148,047
254,454,602
260,939,796
273,030,951
279,663,511
306,092,105
14.Number of participating physicians (#).2
17. Total payments for services provided
by physicians paid through all payment
methods ($). 3
18.Total payments for services provided by
physicians paid through fee-for-service ($).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
213,710
197,023
266,918
209,868
182,746
11,998,933
11,607,119
16,206,261
11,965,539
13,221,951
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
5,990
4,175
5,885
4,610
5,072
487,679
341,618
440,957
568,937
635,020
Insured Surgical-Dental Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
21
26
26
14
23
2,962
3,323
3,363
2,722
2,859
598,383
571,175
385,796
367,905
712,367
23.Number of participating dentists (#). 4
24.Number of services provided (#).
25.Total payments ($).
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 2011–2012,
of the 104 dentists and OMSs registered, 23 billed the Medical Services Plan.
Canada Health Act — Annual Report 2011–2012
55
56
Canada Health Act — Annual Report 2011–2012
Chapter 3: QUEBEC
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.
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
Canada Health Act — Annual Report 2011–2012
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-29), and for employment assistance recipients:
optometric services; dental care for children and employment assistance recipients, and acrylic dental prostheses for
employment 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
(employment 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 2011–2012,
the drug insurance plan covers 3.4 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
58
delivered in a facility maintained by an institution that
operates a hospital or are delivered in association with the
delivery, by intravitreal injection, of an antiangiogenic drug
for the treatment of age-related macular degeneration; any
radiological or anaesthetic service provided by a physician
if required for 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
Services received by regular members of the Canadian Forces,
members of the Royal Canadian Mounted Police (RCMP) and
inmates of federal penitentiaries are not covered by the plan.
There are no health premium charges.
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.
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
Canada Health Act — Annual Report 2011–2012
Chapter 3: QUEBEC
of holding an office or employment for a period of more
than six months become eligible for the plan following a
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.
Costs of hospital services with which a recipient is provided in another province or territory of Canada are paid in
accordance with the terms and conditions of the agreement
on reciprocal billing of insured services regarding hospital insurance agreed to by the provinces and territories of
Canada. These costs are paid either at the established per
diem for hospitalization in a standard ward or in intensive
care proposed by the host province and approved by all the
provinces and territories or, in cases of out-patient 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.
4.2 Coverage During Temporary Absences
In Canada
4.3 Coverage During Temporary Absences
Outside 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.
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.
4.0 PORTABILITY
4.1 Minimum Waiting Period
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.
Canada Health Act — Annual Report 2011–2012
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 out-patient 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.
59
Chapter 3: Quebec
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.
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, 2012, Quebec had 113 institutions operating as
hospital centres for a clientele suffering from acute illnesses.
On that date, 20,658 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, 2010, to March 31, 2011, Quebec hospital institutions
had 725,426 admissions for short stays (including newborns)
and 366,560 registrations for day surgeries. These hospitalizations accounted for 5,189,506 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 is the Health and
Social Services Centre (CSSS). The centres are the result of
the merger of the public institutions whose mission it 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, 2012, there were 239 accredited FMGs and
49 network-clinics in Quebec.
5.2 Physician Compensation
Physicians are remunerated in accordance with the negotiated
fee schedule. Physicians who have withdrawn from the health
insurance plan are paid directly by the patient according to
the fee schedule after the patient has collected from the Régie.
Non-participating physicians are paid directly by their patients
according to the amount charged. 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 2011–2012
the Régie paid an estimated $5,513.2 million to doctors in the
province, while the amount for medical services outside the
province reached an estimated $13.2 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 2011-2012 to institutions operating
as hospital centres for insured health services provided to
residents of Quebec totalled nearly $10.4 billion. Payments to
hospital centres outside Quebec for hospital services totalled
approximately $185.62 million.
Canada Health Act — Annual Report 2011–2012
Chapter 3: Ontario
Ontario
Introduction
Ontario has one of the largest and most complex publicly-funded
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 $47.2 billion (including capital) in
spending for 2011–2012.
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.
Canada Health Act — Annual Report 2011–2012
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. On April 1, 2007, the LHINs assumed responsibility
for funding, planning and integrating health care services
at 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 to ensure equitable access to services in French
for French-speaking Ontarians.
1.2 Reporting Relationship
The Health Insurance Act stipulates that the Minister of
Health and Long-Term Care is responsible for the administration and operation of OHIP, and is Ontario’s public authority
for the purposes of the Canada Health Act.
LHSIA requires each LHIN to prepare an annual report on its
affairs and operations for the previous fiscal year. The Agency
Establishment and Accountability Directive (AEAD), 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 5, 2011.
The Ministry’s accounts and transactions are published annually in the Public Accounts of Ontario. The 2011–2012 Public
Accounts of Ontario was released on September 13, 2012.
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 services1 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) and certain other specified services, for
example, the provision of equipment, supplies and medi­cation
to haemophiliac patients for use at home; and certain specified
home-administered drugs.
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 subsection 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, 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 2011–2012, most physicians submitted claims for all
insured services rendered to insured persons directly to the
Ontario Health Insurance Plan (OHIP), in accordance with
section 15 of the Health Insurance Act, or a limited number
could bill the insured person, as permitted by section 15.2
of the 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.” When a
physician has opted out, the physician bills the patient (not
exceeding the amount payable for the service under the
Schedule (on a “grandparented” basis as of May 13, 2004)
following proclamation of the Commitment to the Future
of Medicare Act on September 23, 2004.
Physicians must be registered to practice medicine in Ontario
by the College of Physicians and Surgeons of Ontario, and be
located in Ontario when rendering the service.
There were approximately 26,818 physicians who submitted
claims to OHIP in 2011–2012. 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.
2.3 Insured Surgical-Dental Services
Certain surgical-dental services are prescribed as insured
services in section 16 of Regulation 552 in the Health Insurance
Act and the Dental Schedule of Benefits. The Health Insurance
Act authorizes OHIP to cover a limited number of procedures
when the procedure is medically necessary, and it is medically
necessary that the insured services be performed in a public
hospital graded under the Public Hospitals Act as Group A, B,
C or D by a dental surgeon who has been appointed to the
dental staff of the public hospital.
Insured surgical-dental services were provided by 262 dental
surgeons in Ontario in 2011–2012.
1. A complete list of hospital services is set out in sections 7-11 of Regulation 552 under the Health Insurance Act.
62
Canada Health Act — Annual Report 2011–2012
Chapter 3: Ontario
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, among others: 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.
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 persion under the Ontario Health Insurance
Plan (OHIP) upon application. To be considered a resident
of Ontario for the purpose of obtaining Ontario health
insurance coverage, Regulation 552 to the Health Inusrance
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).
Canada Health Act — Annual Report 2011–2012
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 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).
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.
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 payor 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).
Approximately 13.2 million Ontario residents were
registered with OHIP and held valid and active health
cards as of March 31, 2012.
3.2 Other Categories of Individual
MOHLTC provides health insurance coverage to residents
of Ontario other than Canadian citizens and Permanent
Residents/Landed Immigrants.
These residents are required to provide acceptable documentation to support their eligible immigration status, 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 resident 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 governmentwide mandate for the delivery of front-facing services to the
residents of Ontario, which also includes the issuance of the
Ontario Photo Health Card.
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Chapter 3: Ontario
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 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.
64
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.
Seasonal Agricultural Farm Workers: Seasonal Agricultural
Farm Workers are persons who have been issued a Work
Permit 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.
Children Born Out-of-Country: A child born to an OHIPeligible woman who was transferred from Ontario to receive
insured health services that were pre-approved for payment
by OHIP is eligible for immediate OHIP coverage provided
that the mother was pregnant at the time of departure from
Ontario.
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 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 section 11(2.1) of the Health
Insurance Act.
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
Canada Health Act — Annual Report 2011–2012
Chapter 3: Ontario
day of the second full month following the date residency
is established (i.e., an “interprovincial waiting period”).
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.
4.2 Coverage During Temporary Absences
in Canada
Insured out-of-province services are prescribed under
sections 28, 28.0.1, and 29 to 32 of Regulation 552 of the
Health Insurance Act.
Ontario adheres to the terms of the Interprovincial Agreement
on Eligibility and Portability; therefore, insured residents who
are temporarily outside of Ontario can use their Ontario health
cards to obtain insured physician (except in Quebec) and
hospital services.
An insured person who leaves Ontario temporarily to travel
within Canada, without establishing residency in another
province or territory, may continue to be covered by OHIP
for a period of up to 12 months.
An insured person who temporarily seeks or accepts employment
in another province or territory may continue to be covered by
OHIP for a period of up to 12 months. If the individual plans to
remain outside Ontario beyond the 12-month maximum, he or
she should apply for coverage in the province or territory where
that person has been working or seeking work.
Insured students who are temporarily absent from Ontario, but
remain within Canada, may be eligible for continuous health
insurance coverage for the duration of their full-time studies,
provided they do not establish permanent residency elsewhere
during this period. To ensure that they maintain continuous
OHIP eligibility, a student should provide the Ministry of Health
and Long-Term Care (MOHLTC) with documentation from
their educational institution confirming registration as a fulltime student. Insured family members (spouses and dependants)
of students who are studying in another province or territory are
also eligible for continuous OHIP eligibility while accompanying
students for the duration of their studies.
In accordance with Regulation 552 of the Health Insurance
Act, most insured residents who want to travel, work or study
outside Ontario, but within Canada, and maintain OHIP
Canada Health Act — Annual Report 2011–2012
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 resident in Ontario for
at least 153 days in each of the two consecutive 12-month
periods before their expected date of departure.
The length of time that a person can receive continuous
Ontario health insurance coverage during an extended
absence outside Canada varies depending on the reason
for the absence as follows:
Reason
OHIP Coverage
Study
Duration of full-time academic studies (unlimited)
Work
Five-year terms (specific residency requirements
must be met for 2 years between absences)
Charitable
Worker
Five-year terms (specific residency requirements
must be met for 2 years between absences)
Vacation/Other
Two-year terms (specific residency requirements
must be met for 5 years between absences)
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Chapter 3: Ontario
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 are covered 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 2011–2012, emergency, medically necessary,
out-of-country physician services were reimbursed at the
Ontario rates set out in regulation under the Health Insurance
Act or the amount billed, whichever was less. Charges for
medically necessary emergency or out-of-country in-patient
and out-patient services are reimbursed only when rendered
in an eligible hospital or health facility. 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.
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.
66
Generally speaking, 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.
There is no formal prior approval process required for services
provided to eligible Ontario residents outside the province,
but within Canada, if the insured service is covered under the
Reciprocal Hospital Billing Agreements.
5.0 ACCESSIBILITY
5.1 Access to Insured Health Services
All insured hospital, physician and surgical-dental services
are available to Ontario residents on uniform terms and
conditions.
All insured persons are entitled to all insured physician,
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 Act 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 Act. In addition, the CFMA prohibits
physicians, practitioners and hospitals from refusing to
Canada Health Act — Annual Report 2011–2012
Chapter 3: Ontario
provide an insured service if an insured person chooses
not to pay a “block fee” for an uninsured service. The Act
further prohibits any person or entity from paying, conferring, or 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.
MOHLTC implemented Health Card Validation (HCV) to
assist health care providers with access to information requested
for Ontario Health Insurance Plan (OHIP) and 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
current 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 registered
physicians.
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. People without a family health care
provider are referred to a family doctor or a nurse practitioner who is accepting new patients in their community.
During 2011–2012, MOHLTC continued to administer
various initiatives in order to improve access to health care
services across the province. Ontario has taken initiatives to
increase physician supply according to evidence-based needs,
and enhance the retention and distribution of physicians in
the province by such measures as:
• working with the Ministry of Training, Colleges and
Universities to increase enrolment in medical schools
for undergraduate spaces;
• expanding postgraduate positions for both family medicine
and Royal College specialty positions;
• increasing 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
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.
• Supporting the HealthForceOntario Marketing and
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:
Two initiatives to improve access across Ontario, including
rural and northern communities, are the HealthForceOntario
Northern and Rural Recruitment and Retention (NRRR)
Initiative and the Northern Health Travel Grant (NHTG)
Program.
•
•
•
•
•
selected cardiovascular services;
selected cancer services;
chronic kidney disease services;
critical care services; and
organ and tissue donation and organ transplantation.
Primary Health Care: During 2011–2012, 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
Canada Health Act — Annual Report 2011–2012
Recruitment Agency to help recruit and retain health care
professionals in Ontario communities that need them.
• HealthForceOntario Northern and Rural Recruitment
and Retention Initiative: The NRRR Initiative (launched
April 2010) supports the recruitment and retention of
physicians in rural and northern communities. The NRRR
Initiative provides financial recruitment incentives to physicians and new physician graduates to set up new practices in
a northern or highly rural community with a Rurality Index
for Ontario score of 40 or more, or in one of the five major
northern urban referral centers (Thunder Bay, Sudbury,
North Bay, Sault Ste. Marie and Timmins).
67
Chapter 3: Ontario
• 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.
health, and to reward physicians groups that worked in collaboration with other service providers.
With respect to insured surgical-dental services, MOHLTC
negotiates changes to the Schedule of Benefits for 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, 2003, and continues to be in effect.
5.3 Payments to Hospitals
5.2 Physician Compensation and
Dental-Surgical Services
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 2011–2012, 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
(CCM), Family Health Group (FHG), Family Health Network
(FHN), Family Health Organization (FHO), Community
Health Centres (CHC), Rural and Northern Physician Group
Agreement (RNPGA), Group Health Centre (GHC), Blended
Salary Model (BSM), and specialized agreements. Family
Health Teams (FHTs) build upon existing primary health
care physician funded models by providing funding for interdisciplinary teams of providers such as nurse practitioners,
nurses, social workers and dietitians. FHTs are located across
Ontario, in both urban and rural settings, ranging in size,
structure, scope and governance. Physicians participating
in FHTs are funded by one of three compensation options
that include: Blended Capitation (such as FHN or FHO),
Complement Based Models (RNPGA or other specialized
agreements) and BSM (for community-sponsored FHTs).
MOHLTC negotiates physician funding with the Ontario
Medical Association (OMA). The last four-year Physician
Services Agreement expired on March 31, 2012. Its focus was
on access to family health care and reducing congestion in
emergency departments. The Agreement provided a 3% one
time payment to physicians in the first year of the Agreement
and targeted increases to the Schedule of Benefits of 5% in the
second year, 3% in the third year and 4.25% in the fourth year.
Funding was also provided to support stabilizing physician
human resources and government priorities, such as mental
68
The Ontario 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 in respect of above-average growth in the
volume of service in specific geographic locations. Payments
are made to hospitals on a semi-monthly basis.
Beginning April 1, 2012, Ontario will be moving to a PatientBased Funding system for funding hospitals. Patient-Based
Funding (PBF) will shift 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. PBF
offers an integrated approach to health system funding and puts
the patient at the forefront of all health care decisions through
bundling payments to health service providers and adopting
a ‘money follows the patient’ principle. PBF will expand on
the Ontario Wait Time Strategy funding approach to link the
majority of hospitals’ funding to the types, volumes and quality
of care they provide. PBF is a significant shift from the way
Ontario hospitals are currently funded, still largely based on
historically-derived global budgets established in 1969.
PBF is comprised of two key components: Health Based
Allocation Model (HBAM) and Quality-Based Procedures
(QBP) funding, which will together comprise 70% of the
Health Service Provider’s (HSP) total funding by the end
of a three-year implementation period.
• Organizational-Level funding: allocated to HSPs as determined by characteristics of the population being served.
A specific model, HBAM, is used to allocate funding in
the hospital and community care access centre sectors; this
allocation neither creates nor reduces overall funding but
is a mechanism to spread the funding envelope.
• Quality-Based Procedures: specific patient groups that
will allow the health system to achieve better quality and
system efficiencies through utilizing a ‘price x volume’
approach. The price for each patient group will be grounded
on evidence-informed practices and agreed-upon patient
clinical pathways developed by clinical and administrative
leadership.
Canada Health Act — Annual Report 2011–2012
Chapter 3: Ontario
• Global budgets will continue to be used for activities that
delivery of high quality care and fiscal sustainability and plays
a key role in advancing the government’s quality agenda and
its Action Plan for Health Care.
QBPs are an integral part of PBF. QBPs are specific groups
of patient services that present opportunities for HSPs to
share clinical, evidence-informed best practices that will
allow the health care system to achieve even better quality
and efficiencies. QBPs use an evidence-informed approach
to targeted clinical groups at the provincial level. QBP prices
are structured and priced appropriately both to provide
incentive and adequately reimburse providers for delivering
high quality care.
When they assumed responsibility for their local health care
systems, Local Health Integration Networks (LHINs) nego­
tiated 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. While the vision is for three-year agreements,
the fiscal reality is that funding projections for three years are
unrealistic. As such, the two-year 2008–2010 H-SAA will be
amended for another term to cover 2012–2013, with updates
to comply with legislative and policy changes. Once signed,
the 2012–2013 Amending Agreement will be effective from
April 1, 2012 through March 31, 2013.
cannot be modeled or that are unique, such as out-patient
service costs.
QBPs have been identified using an evidence-based framework
that offers four perspectives for identifying opportunity areas
that have the potential for reducing variation, improving outcomes, safety, efficiency and/or patient centeredness. All four
quadrants of the framework are quality-driven and reinforce
the importance of the alignment between quality and funding.
The implementation of PBF will be 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, and to support the system transformation agenda of The Excellent Care for All Act (ECFAA).
ECFAA and PBF implementation will combine activity-based
funding with global funding to create a system that promotes
access, quality and efficiency, and establishes payment levers
to advance policy and system objectives while still ensuring
overall cost containment. PBF implementation is a critical
structural reform for reducing health spending growth from
current 6%–7% annual increases to 3.1% by 2012–2013.
Internationally, PBF models have been implemented since
1983. Although Ontario is one of the last leading jurisdictions
to move down this path. This puts the province in a unique
position to learn from international best practices and lessons
learned by others to create a funding model that is best suited
for Ontario.
PBF promotes care in the most appropriate setting for a
patient/client/resident’s level of acuity and links providers’
funding to services delivered to ensure that appropriate service
levels are provided and access is maintained. PBF supports
system capacity planning and quality improvement through
directly linking funding to patient outcomes. The Ontario
government’s Excellent Care for All Strategy represents a
significant culture shift in the province’s health care system
and a change in the province’s approach to health care funding
through a quality agenda. The funding approach will create
a financial environment that supports the business case for
providers to invest in quality improvement; to provide funding
that reflects the quality of care that providers deliver; and to
promote evidence-based practice. PBF has been identified as
an important mechanism to strengthen the link between the
Canada Health Act — Annual Report 2011–2012
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
strive to describe:
• person experience (e.g.,emergency room length of stay);
• organizational health (e.g., current ratio [consolidated],
total margin [consolidated]); and
• patient access and outcomes (e.g., global volumes,
i.e., target volumes expected for rehabilitation, complex
continuing care, mental health, total acute care, wait
time volumes for MRI, CT, cataract surgery, hip and
knee surgery, and selected cardiac services).
Indicators have a performance standard and target that are
designed to encourage the hospital to move in a particular
direction within the sector. 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 available to the LHIN. The hospital and LHIN may
develop a Performance Improvement Plan to get the hospital
back on track to achieving its targets.
Payments to hospitals have traditionally been based on
historical global allocations and multi-year incremental
increases that incorporate population growth and anticipated service demands within the available provincial
69
Chapter 3: Ontario
budget. The Ministry began implementation of the Health
System Funding Reform (HSFR) in 2012–2013. Over the
fiscal years 2012–2013 to 2014–2015, HSFR will shift much
of Ontario’s health care system funding for hospitals away
from the current global funding allocation towards PBF, to
further support quality, efficiency and effectiveness in the
health care system.
The Interprovincial Hospital Reciprocal Billing Agreements are
a convenient administrative arrangement in which provincial/
territorial governments reimburse hospitals in their jurisdictions for insured services provided to patients from other
provinces/territories.
70
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.
6.0 RECOGNITION GIVEN TO
FEDERAL TRANSFERS
The Government of Ontario publicly acknowledged the federal
contributions provided through the Canada Health Transfer in
its 2011–2012 publications.
Canada Health Act — Annual Report 2011–2012
Chapter 3: Ontario
Registered Persons
2007–2008
1. Number as of March 31st (#).
12,700,000
2008–2009
2
12,800,000
2009–2010
2
12,900,000
2010–2011
2
13,100,000
2011–2012
2
13,212,728
2
Insured Hospital Services Within Own Province or Territory
Public Facilities
2007–2008
Private For-Profit Facilities
2009–2010
2010–2011
2011–2012
150
3
149
3
149
3
149
3
147
3
13,600,000,000
4
14,200,000,000
4
14,800,000,000
4
15,527,899,500
4
16,173,889,100
4
2. Number (#).
3. Payments for insured health services ($).
2008–2009
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4. Number of private for-profit facilities
providing insured health services (#).
not available
5
not available
5
not available
5
not available
5
not available
5
5. Payments to private for-profit facilities
for insured health services ($).
not available
5
not available
5
not available
5
not available
5
not available
5
Insured Hospital Services Provided to residents in another province or territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
7,130
9,457
8,185
8,231
6,365
45,712,000
65,183,888
64,688,077
68,384,505
46,960,837
166,373
161,193
138,594
130,855
116,541
31,052,000
38,030,901
36,399,952
35,431,819
33,598,383
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
24,327
21,869
28,223
28,420
30,348
113,663,332
136,036,532
91,456,638
52,706,316
42,559,353
12.Total number of claims, out-patient (#).
not available
6
not available
6
not available
6
not available
6
not available
6
13.Total payments, out-patient ($).
not available
7
not available
7
not available
7
not available
7
not available
7
2. These estimates represent the number of Valid and Active Health Cards (have current eligibility and resident has incurred a claim in the last 7 years).
3. Number represents all publicly-funded hospitals excluding specialty psychiatric hospitals. Specialty psychiatric hospitals are excluded in order to conform to
CHAAR reporting guide.
4. Amount represents funding for all public hospitals excluding specialty psychiatric hospitals.
5. Data are not collected in a single system in MOHLTC. Further, the MOHLTC is unable to categorize providers/facilities as “for-profit” as MOHLTC does not have
financial statements detailing service providers’ disbursement of revenues from the Ministry.
6.
Included in #10.
7.
Included in #11.
Canada Health Act — Annual Report 2011–2012
71
Chapter 3: Ontario
Insured Physician Services Within Own Province or Territory
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
23,859
24,411
25,166
25,995
26,818
40
39
35
34
32
0
8
0
8
0
8
0
8
0
8
17. Total payments for services provided
by physicians paid through all payment
methods ($).
8,410,478,000
9
9,324,794,000
9
10,033,761,000
9
9,070,713,617
9
11,332,919,800
9
18.Total payments for services provided by
physicians paid through fee-for-service ($).
5,962,775,787
16.Number of non-participating physicians (#).
6,528,353,572
6,812,333,798
7,052,261,365
7,508,636,523
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
759,570
683,377
596,430
723,766
536,447
25,180,900
26,471,536
26,204,597
25,237,480
25,252,852
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
211,323
247,741
216,715
213,717
234,420
37,901,297
54,780,594
41,652,064
12,455,597
7,922,281
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2v007–2008
2008–2009
2009–2010
2010–2011
2011–2012
317
291
277
282
262
91,540
99,212
99,427
96,797
96,735
13,423,384
13,916,464
14,324,505
13,525,890
13,532,519
8. Ontario has no non-participating physicians, only opted-out physicians who are reported under item #15.
9. Total Payments includes payments made to Ontario physicians through Fee-for-Service, Primary Care, Alternate Payment Programs, and Academic Health Science
Centres and the Hospital On Call Program. Services and payments related to Other Practitioner Programs, Out-of-Country/Out-of-Province Programs, and
Community Labs are excluded.
— Fiscal Year 2009–2010 has been updated to agree with Public Accounts.
— Fiscal Year 2010–2011 has been updated to agree with Public Accounts.
— Fiscal Year 2011–2012 is based on Interim (Unpublished) Public Accounts.
72
Canada Health Act — Annual Report 2011–2012
Chapter 3: MANITOBA
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.
Manitoba
Introduction
Manitoba Health provides leadership and support to protect, promote and preserve the health of all Manitobans. 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.
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.
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 2011–2012 included:
There were no legislative amendments to the Act or the
regulations in the 2011–2012 fiscal year that affected the
public administration of the Plan.
• Launched the Cancer Wait Time Strategy, “Transforming
1.2 Reporting Relationship
• Continued to support initiatives, such as A Family Doctor
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.
the Cancer Patient Journey in Manitoba.”
for Every Manitoban by 2015.
• Increased number of physicians in Manitoba, demonstrating
continued improvement in their recruitment and retention.
• Supported medical enrolment and rural medical studies
and kept medical school tuitions affordable.
• Improved services, gender-based research and policies and
increased awareness about women’s health issues through
The Women’s Health Strategy.
• Stakeholder training in area-specific quality improvement
methodology (i.e. Lean Six Sigma, Advanced Access and
Releasing Time to Care).
• Completed construction of two renal health dialysis
units in Hodgson, the Western Manitoba Cancer Centre,
a Bilingual Service Centre, the South Winnipeg Birth
Centre, and redevelopment of Victoria General Hospital’s
Emergency and Out-patient departments.
Canada Health Act — Annual Report 2011–2012
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 2011–2012
fiscal year and is contained in the Manitoba Health Annual
Report, 2011–2012. It is available at http://www.gov.mb.ca/
health/ann/index.html.
73
Chapter 3: MANITOBA
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
Sections 46 and 47 of the Health Services Insurance Act, as
well as the Hospital Services Insurance and Administration
Regulation (M.R. 48/93), provide for insured hospital services.
As of March 31, 2012, 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. Manitoba Health is
sensitive to new developments in the health sciences.
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, 2012, there were 2,552 registered in Manitoba.
A physician, by giving notice to the Minister in writing,
may elect to collect the fees for medical services rendered
to insured persons other than from the Minister, in accordance with section 91 of the Act and section 5 of the Medical
Services Insurance Regulation. The election to opt out of
the health insurance plan takes effect on the first day of the
month following a 90-day period from the date the Minister
receives the notice.
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
74
service under the Act or regulations. No physicians opted out
of the medical plan in 2011–2012.
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 2011–2012, a number of new insured
services were added to a revised fee schedule. The Physician’s
Manual can be viewed on-line at: http://www.gov.mb.ca/
health/manual/index.html.
In order for a medical service to be added to the list of those
covered by Manitoba Health, 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 2011–2012.
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
Canada Health Act — Annual Report 2011–2012
Chapter 3: MANITOBA
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 2011–2012.
3.0UNIVERSALITY
3.1Eligibility
The Health Services Insurance Act defines the eligibility of
Manitoba residents for coverage under the provincial health
care insurance plan. Section 2(1) of the Act states that a
resident is a person who is legally entitled to be in Canada,
makes his or her home in Manitoba, is physically present
in Manitoba for at least six months in a calendar year, and
includes any other person classified as a resident in the regulations, but does not include a person who holds a temporary
resident permit under the Immigration and Refugee Protection
Act (Canada), unless the Minister determines otherwise, or
is a visitor, transient or tourist.
The Residency and Registration Regulation (M.R. 54/93)
extends the definition of residency. The extensions are found
in sections 7(1) and 8(1). Section 7(1) allows missionaries,
individuals with out-of-country employment and individuals
Canada Health Act — Annual Report 2011–2012
undertaking sabbatical leave to be outside Manitoba for up
to two years while still remaining residents of Manitoba.
Students are deemed to be Manitoba residents while in
full-time attendance at an accredited educational institution. Section 8(1) extends residency to individuals who are
legally entitled to work in Manitoba and have a work permit
of 12 months or more and to individuals who hold study
permits of 6 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.”
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 Warrelated 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)).
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, 2012, there were 1,265,059 residents registered
with the Manitoba Health Services Insurance Plan.
75
Chapter 3: MANITOBA
There is no provision for a resident to opt out of the Manitoba
Health Plan.
3.2 Other Categories of Individual
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. As of March 31, 2012, there were 5,275 individuals on
work permits and 589 individuals on study permits covered
under the MHSIP. The definition of “resident” under the
Health Services Insurance Act allows the Minister of Health or
the Minister’s designated representative to provide coverage
for holders of a Minister’s permit under the Immigration and
Refugee Protection Act (Canada). No legislative amendments
to the Act or the regulations in the 2011–2012 fiscal year
affected universality.
4.0PORTABILITY
4.1 Minimum Waiting Period
The Residency and Registration Regulation (M.R. 54/93, section 6) identifies the waiting period for insured persons from
another province or territory. A resident who lived in another
Canadian province or territory immediately before arriving
in Manitoba is entitled to benefits on the first day of the third
month following the month of arrival.
4.2 Coverage During Temporary Absences
in Canada
The Residency and Registration Regulation (M.R. 54/93 section 7(1)) defines the rules for portability of health insurance
during temporary absences in Canada.
Students are considered residents and will continue to receive
health coverage for the duration of their full-time enrolment at
any accredited educational institution. The additional requirement is that they intend to return and reside in Manitoba after
completing their studies. Manitoba has formal agreements with
all Canadian provinces and territories for the reciprocal billing
of insured hospital services. Manitoba has a bilateral agreement
with the Province of Saskatchewan for Saskatchewan residents
who receive care in Manitoba border communities.
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.
76
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.
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 humani­
tarian 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.
Coverage for all these categories is subject to amounts detailed in
the Hospital Services Insurance and Administration Regulation
(M.R. 48/93). Hospital services received outside Canada due to
an emergency or a sudden illness, while temporarily absent, are
paid as follows:
In-patient services are paid based on a per-diem rate according
to hospital size: • 1–100 beds: $280
• 101–500 beds: $365
• over 500 beds: $570
Out-patient services are paid at a flat rate of $100 per visit or
$215 for haemodialysis.
The calculation of these rates is complex due to the diversity
of hospitals in both rural and urban areas.
Physician services received in the United States are paid at the
equivalent Manitoba rate for similar services.
Canada Health Act — Annual Report 2011–2012
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.
In cases where a patient is referred out of country, and receives
the prior approval of Manitoba Health, hospital services are
paid at a minimum of 75 percent of the hospital’s charges for
insured services. Payment for hospital services is made in U.S.
funds (the Hospital Services Insurance and Administration
Regulation, sections 15-23). In instances where Manitoba
Health has given prior approval for services provided outside
Canada, Manitoba Health will consider additional funding
based on financial need.
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.
In July 2001, the Health Services Insurance Act, the Private
Hospitals Act and the Hospitals Act were amended to strengthen
and protect public access to the health care system. The
amendments include:
• changes to 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
• ensuring 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
Canada Health Act — Annual Report 2011–2012
three Quick Care Clinics, mobile Primary Care in communities across the province, and introduced more opportunities
and supports for Manitobans to self-manage their health
care. Investment also continued in existing initiatives that
enhance capacity, quality and efficiency in primary care, such
as the Physician Integrated Network, TeleCARE Manitoba
(a chronic disease self-management resource for congestive heart failure and diabetes), and an After-Hours Call
Community Network pilot (a network of general practitioners
linked to patients through the 24-hour Health Links-Info
Santé service). Since 2008, Manitoba Health funded and coordinated over 30 primary and specialty clinics to successfully
complete the Advanced Access training, enabling them to offer
patients same-day access to a primary care provider and fiveday access to a specialist. The Winnipeg Birth Centre opened
in October 2011. In addition to providing an alternative option
to support low risk childbirth outside of a hospital or home, the
Birth Centre offers various maternal and child health programs.
All Manitobans have access to hospital services including
acute care, psychiatric extended treatment, mental health,
palliative, chronic, long-term assessment/rehabilitation, and
to personal care facilities. There has been a shift in focus from
hospital beds to community services, out-patients and day
surgeries, which are also insured services.
The Western Manitoba Cancer Centre (WMCC) opened in
June 2011 and is located at the Brandon Regional Health
Centre (BRHC). This $24 million state-of-the-art facility is
the first location outside of Winnipeg to provide radiation
therapy and increases the overall capacity for cancer services
within the province. In addition to radiation therapy, the
WMCC provides a broad range of cancer treatment and
support services including:
• chemotherapy;
• a simulation suite with a CT scanner for treatment planning;
• advanced information and communication technologies
that will transmit data and pictures between the WMCC
and CancerCare Manitoba (CCMB) in Winnipeg, allowing staff at both locations to interact around detection,
surveillance and treatment options;
• out-patient care services;
• supportive care areas, including a quiet care and comfort
area for patients and family to relax; and
• a staff area with a lunch room, showers, washroom, locker
areas, resource area with computer access and reference
material.
In June 2011, Manitoba announced the implementation
of the first-in-Canada, Cancer Wait Time Strategy entitled
“Transforming the Cancer Patients’ Journey in Manitoba.”
This $40 million comprehensive and aggressive strategy
77
Chapter 3: MANITOBA
will 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.
As part of this initiative, in December 2011, Manitoba’s first
regional CancerCare hub was announced in Morden-Winkler.
The CancerCare hub expands on the chemotherapy services
currently available through the community cancer programs
and is the first of many to provide world-class cancer care no
matter where you live by co-ordinating access to expanded
services like cancer screening and early detection services,
cancer risk-reduction programs and palliative care.
Manitobans access to renal health dialysis services increased
through the addition of ten dialysis stations at the Winnipeg
Health Sciences Centre site and the opening of two new renal
health dialysis units each containing four dialysis stations
(one is located at the Gimli Community Health Centre to
serve residents of the Interlake communities and the second
is located in the Russell District Health Centre to serve
residents in communities central western Manitoba). The
launch of a pilot renal health clinic Telehealth project located
in a northern Manitoba community aimed to increase access
to support services for people living with chronic kidney
disease in the surrounding area.
In the Provincial Nursing Stations, measures were taken to
support access to primary health care professionals and specialists through programming such as MBTeleheath, on-going
staff training, and increased communications with local and
regional health authorities. Acute and emergency care has
been enhanced by increasing the drug formulary, acquisition
of new equipment, and by staff recruitment and retention
initiatives.
The MBTelehealth program continues to grow and currently
has over 110 sites in Manitoba, including 24 sites in First
Nation communities. In 2011–12 MBT total events reached
over 16,000, of which approximately 76% were clinical services. Patients have access to over 200 specialists. Specialties
include, but are not limited to, oncology, dermatology, renal
health, and psychiatry. Other uses include continuing education, administrative meetings and televisitation. Provider and
patient response to the program continues to be very positive
and demand for new sites continues to be high.
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. Throughout 2011–2012, the
Patient Access Registry Tool, an electronic booking request
and wait-time/wait list management system, was implemented throughout the Winnipeg Regional Health Authority
(WRHA) for adult elective surgery.
78
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 management strategies, including improved appropriateness of services.
Manitoba Health continues to support the provision of
accessible services in rural and northern regional health
authorities, including the following projects and funding
that were announced in 2011: a $42.4 million investment
in reduced wait time for diagnostic testing, cardiac and
orthopedic services, including investments at Brandon
Regional Health Centre and Boundary Trails Health Centre
in Morden-Winkler; a 45,000 square foot expansion of the
Bethesda Hospital Emergency Department in Steinbach;
a $14.1 million expansion and renovation of Ste. Anne
Hospital; an $8.7 million investment in new diagnostic
equipment, including a CT scanner for Bethesda Hospital,
and a new bone densitometer at Brandon Regional Health
Centre; and the introduction of dental surgery services at
Swan Valley Health Centre in Swan River.
Manitoba continues to have growth in the number of active
practicing nurses through expansions to the nursing education programs and strategies of the Nurses Recruitment and
Retention Fund (NRRF). According to the registration data
received from the Colleges of Registered Nurses, Registered
Psychiatric Nurses and Licensed Practical Nurses, there were
17,265 active practicing nurses in Manitoba in 2011. This is a
net gain of 147 more nurses than in 2010. There remain; however, ongoing nursing resource challenges in some rural and
northern regions, and in specialty care areas in Winnipeg.
Manitoba has increased nursing education seats throughout
the province resulting in a more than doubling of enrolments
in the last 10 years.
The NRRF also contributes significantly to improving the
nursing supply in Manitoba through initiatives such as relocation
assistance; the Conditional Grant Program, which encourages
new graduates to work in rural and northern regions (outside
Winnipeg and Brandon); the personal care home grant; and
funding for continuing education and specialty education
programs. The Extended Practice Regulation 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 register has grown from 4 in June 2005 to 110 as of
the December 31, 2011 registration year.
Manitoba Health has developed and provided funding for a
number of initiatives to address shortages in various allied
health professions. Examples include: increasing seats in
the ultrasound training program, the medical laboratory
technologist training program and the medical radiologic
Canada Health Act — Annual Report 2011–2012
Chapter 3: MANITOBA
technologist training program as well as reserving seats in
training programs in other jurisdictions, such as the nuclear
medicine technologist training program in Alberta and
the prosthetics and orthotics training program in British
Columbia. Along with reserving these seats students are
expected to sign return of service agreements to return to
Manitoba for employment post graduation for a specified
period of time.
Manitoba continues to experience increases in the number of
new physicians registering with the licensing body. Manitoba
has increased the number of grants available 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. There have been significant increases in the
number of students accessing grants and agreeing to practice
in under-serviced communities since improvements to the
Program came into effect in the Fall of 2011. It is expected
that increased Program enrollment to continue.
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, and there has been significant take up
of the program, with many physicians moving to rural and
northern Manitoba.
In an effort to support the repatriation of Manitobans/
Canadians studying abroad back to Manitoba, the Province
has established a repatriation coordinator. The coordinator
chairs a repatriation working group which aims to develop
potential pathways for Manitoba medical students/residents
to return to Manitoba for training and practice opportunities.
Through the current assessment and training programs, foreigntrained physicians can achieve conditional licensure to practice
medicine in return for agreeing to work in a sponsoring rural
regional health authority. Upon successful completion of the
assessments, candidates may be recommended for conditional
licensure and, upon commencement of practice, are linked with
a physician mentor for a minimum of 12 months. The Province
supports assessment training programs for foreign-trained
family medicine and specialist physicians.
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
Canada Health Act — Annual Report 2011–2012
to the Health Services Insurance Act related to physician compensation during the 2011–12 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. Alternatefunded 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 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 quasi-judicial 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
79
Chapter 3: MANITOBA
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 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.
80
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 2011–2012 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.
Canada Health Act — Annual Report 2011–2012
Chapter 3: MANITOBA
Registered Persons
1. Number as of March 31st (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
1,186,386
1,209,401
1,228,246
1,230,270
1,265,059
Insured Hospital Services Within Own Province or Territory
Public Facilities
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
97
97
96
96
96
not available
not available
not available
not available
not available
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
1
1
1
1
1
1,289,964
1,553,438
1,570,832
1,541,540
2,005,150
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 ($).
Insured Hospital Services Provided to residents in another province or territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
2,823
3,280
2,626
2,844
2,899
18,731,739
24,489,298
21,612,535
27,092,558
26,478,561
31,329
35,957
28,729
30,983
29,070
6,933,920
9,662,718
8,655,118
10,454,203
10,706,338
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
549
658
552
634
646
1,791,864
3,252,651
1,924,044
2,454,364
1,913,457
8,796
10,121
10,097
10,706
11,311
2,692,096
2,650,500
2,954,321
3,022,630
3,226,581
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
Canada Health Act — Annual Report 2011–2012
81
Chapter 3: MANITOBA
Insured Physician Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
2,050
2,073
2,121
2,276
2,322
0
0
0
0
0
not applicable
not applicable
not applicable
not applicable
not applicable
17. Total payments for services provided
by physicians paid through all payment
methods ($).
721,552,291
789,101,000
843,087,000
920,890,000
927,916,000 18.Total payments for services provided by
physicians paid through fee-for-service ($).
459,573,573
476,227,782
552,890,200
553,924,806
595,083,828
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of non-participating physicians (#).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
290,775
243,881
237,192
267,122
231,683
9,985,987
9,721,570
10,287,990
9,909,927
10,989,977
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
6,414
7,446
6,768
7,226
8,285
701,829
725,382
627,563
953,272
703,353
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
82
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
120
131
135
133
131
4,616
4,833
5,950
5,475
5,290
1,107,357
1,175,314
1,701,655
1,522,545
1,468,524
Canada Health Act — Annual Report 2011–2012
Chapter 3: Saskatchewan
1.0 PUBLIC ADMINISTRATION
1.1 Health Care Insurance Plan and
Public Authority
The provincial government is responsible for funding and
ensuring the provision of insured hospital, physician and
surgical-dental services in Saskatchewan. Section 6.1 of The
Department of Health Act authorizes that the Minister of
Health may:
Saskatchewan
• pay part of, or the whole of, the cost of providing health
Introduction
• make grants or loans, or provide subsidies to regional
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.
• pay part of, or the whole of, the cost of providing health
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: Specialized Programs;
Community and Primary Health; and Strategy and
Performance Management. The Saskatchewan Surgical
Initiative; Communications Branch; and the Provincial
Kaizen Promotion office 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 2011–2012
services for any persons or classes of person who may be
designated by the Lieutenant Governor-in-Council;
health authorities, health care organizations or municipalities for providing and operating health services or public
health services;
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 provides the
authority to establish 12 regional health authorities, replacing
the former 32 district health boards.
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.
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
83
Chapter 3: Saskatchewan
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:
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
• a report on the activities of the regional health authority; and
• a detailed, audited set of financial statements.
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 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.
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.
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.
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.
The most recent audits were for the year ended March 31,
2012.
The audits of the Government of Saskatchewan, regional health
authorities and Saskatchewan Cancer Agency are tabled in the
Saskatchewan Legislature each year. The reports are available
to the public directly from each entity or are available on their
websites.
The Office of the Provincial Auditor for Saskatchewan also
prepares reports to the Legislative Assembly of Saskatchewan.
These reports are designed to assist the government in
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.
84
The Act sets out the accountability requirements for regional
health authorities and health care organizations. These requirements include submitting annual operational, financial and
health service plans for ministerial approval (sections 50–51);
establishing community advisory networks (section 28); and
reporting critical incidents (section 58). The Minister also has
the authority to establish a provincial surgical registry to help
manage surgical wait times (section 12). The Minister retains
authority to inquire into matters (section 59); appoint a public
administrator if necessary (section 60); and approve general
and staff practitioner by-laws (sections 42–44).
Funding for hospitals is included in the funding provided to
regional health authorities.
A comprehensive range of insured services is provided by
hospitals. These may include: public ward accommodation;
necessary nursing services; the use of operating room and
case room facilities; required medical and surgical materials
and appliances; x-ray, laboratory, radiological and other diagnostic procedures; radiotherapy facilities; anaesthetic agents
and the use of anaesthesia equipment; physiotherapeutic
procedures; all drugs, biological and related preparations
required for hospitalized patients; and services rendered by
individuals who receive remuneration from the hospital.
Hospitals are grouped into the following five categories:
Community Hospitals; Northern Hospitals; District
Hospitals; Regional Hospitals; and Provincial Hospitals, so
people know what they can expect 24 hours a day, 365 days
a year at each hospital. While not all hospitals will offer the
same kinds of services, reliability and predictability means:
• 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.
Canada Health Act — Annual Report 2011–2012
Chapter 3: Saskatchewan
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, 2012, there were 1,985 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, 2012, there were no opted-out physicians
in Saskatchewan.
Insured physician services are those that are medically necessary, are covered by the Medical Services Plan of the Ministry
of Health, and are listed in the Physician Payment Schedule
of the Saskatchewan Medical Care Insurance Payment
Regulations (1994) of The Saskatchewan Medical Care
Insurance Act.
A process of formal discussion between the Medical Services
Plan and the Saskatchewan Medical Association addresses
new insured physician services and definition or assessment
rule revisions to existing selected services. The Executive
Director of the Medical Services Branch manages this process. When the Medical Services Plan covers a new insured
Canada Health Act — Annual Report 2011–2012
physician service, or revisions to definitions or assessment
rules for existing services occur, a regulatory amendment is
made to the Physician Payment Schedule.
Although formal public consultations are not held, any
member of the public may make recommendations about
physician services to be added to the Medical Services Plan.
2.3 Insured Surgical-Dental Services
Dentists may opt out or not participate in the Medical Services
Plan, but if doing so, they must opt out of all insured surgicaldental services. The dentist must also advise beneficiaries that
the surgical-dental services to be provided are not insured
and that the beneficiary is not entitled to reimbursement for
those services. Written acknowledgement from the beneficiary
indicating that he or she understands the advice given by the
dentist is also required. There were no opted-out dentists in
Saskatchewan as of March 31, 2012.
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.
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 surgicaldental services obtained outside Canada without prior written
85
Chapter 3: Saskatchewan
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
her home and is ordinarily present in Saskatchewan, or any
other person declared by the Lieutenant Governor-in-Council
to be a resident. Canadian citizens and permanent residents
of Canada relocating from within Canada to Saskatchewan
are generally eligible for coverage on the first day of the third
month following establishment of residency in Saskatchewan.
Returning Canadian citizens, the families of returning members
of the Canadian Forces, international students, and international
workers are eligible for coverage on establishing residency in
Saskatchewan, provided that residency is established before
the first day of the third month following their admittance
to Canada.
The following persons are not eligible for insured health
services in Saskatchewan:
• members of the Canadian Forces 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
RCMP, 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, 2011, was 1,084,127.
3.1Eligibility
3.2 Other Categories of Individual
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.
Other categories of individual 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.
Eligibility is limited to residents. A “resident” means a person
who is legally entitled to remain in Canada, who makes his or
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 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.
86
Canada Health Act — Annual Report 2011–2012
Chapter 3: Saskatchewan
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, 2011, there were 9,650 such temporary residents
registered with the Saskatchewan Ministry of Health.
4.0PORTABILITY
4.1 Minimum Waiting Period
In general, insured persons from another province or territory
who move to Saskatchewan are eligible on the first day of the
third month following establishment of residency. However,
where one spouse arrives in advance of the other, the eligibility
for the later arriving spouse is established on the earlier of a)
the first day of the third month following arrival of the second
spouse; or b) the first day of the thirteenth month following the
establishment of residency by the first spouse.
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:
4.2 Coverage During Temporary Absences
in Canada
• education: for the duration of studies at a recognized edu-
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 2011–2012.
• contract employment of up to 24 months; and
• vacation and travel of up to 12 months.
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); • employment of up to 12 months (no documentation
required); and
• vacation and travel of up to 12 months.
Canada Health Act — Annual Report 2011–2012
cational facility (confirmation by the facility of full-time
student status and expected graduation date are required);
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
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.
87
Chapter 3: Saskatchewan
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
out-of-country cancer treatment requests. If approved,
the Ministry of Health will pay the full cost of treatment, excluding any items that would not be covered
in Saskatchewan.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
To ensure that access to insured hospital, physician and 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
within four years, 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
entire continuum of care — from initial contact with a health
provider, to surgery, to recuperation in the community.
88
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 25 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, 2012, there were 1,985 physicians licensed
to practice in the province and eligible to participate in
the Medical Care Insurance Plan. Of these, 1,024 (51.6 per­
cent) were family practitioners and 961 (48.4 percent)
were specialists.
As of March 31, 2012, there were approximately 425 practising dentists and dental surgeons located in all major centres
in Saskatchewan. Ninety three 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 2011–2012 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-of-service
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 2011–2012
Chapter 3: Saskatchewan
• The Northern Medical Services Program is a tripartite
5.3 Payments to Hospitals
• The Northern Telehealth Network provides physicians
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.
endeavour of the Ministry of Health, Health Canada and
the University of Saskatchewan to help stabilize the supply
of physicians in northern Saskatchewan.
in remote or isolated areas with access to colleagues,
specialty expertise and continuing education.
Other Programs
• 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 Alternate Payments and 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
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.
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.
6.0 RECOGNITION GIVEN TO
FEDERAL TRANSFERS
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.
The Government of Saskatchewan publicly acknowledged the
federal contributions provided through the Canada Health
Transfer (CHT) in the Ministry’s 2011–2012 Annual Report,
the Government of Saskatchewan 2011–2012 Budget and
related documents, its 2011–2012 Public Accounts, and the
Quarterly and Mid-Year Financial Reports. These documents
were tabled in the Legislative Assembly and are publicly available to Saskatchewan residents. Federal contributions have also
been acknowledged on the Ministry of Health website, in news
releases and issue papers, and in speeches and remarks made at
various conferences, meetings and public policy forums.
Fee-for-service is the most widely used method of compensating physicians for insured health services in Saskatchewan,
although sessional payments, 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 2011–2012 amounted
to $794.9 million: $457.3 million for fee-for-service billings;
$27.1 million for Specialist Emergency Coverage Programs;
and $310.5 million in non-fee-for-service expenditures. There
was also an additional $27.1 million for other Saskatchewan
Medical Association and bursary programs.
Canada Health Act — Annual Report 2011–2012
89
Chapter 3: Saskatchewan
Registered Persons
1. Number as of March 31st (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
1,014,649
1,035,544
1,036,284
1,070,477
1,084,127
2
Insured Hospital Services Within Own Province or Territory
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
67
67
67
66
66
1,277,632,000
3
1,402,109,000
3
1,556,078,000
3
1,636,013,000
3
1,694,858,000
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4. Number of private for-profit facilities
providing insured health services (#).
0
0
0
3
5
5. Payments to private for-profit facilities
for insured health services ($).
0
0
0
Not Available
4
Not Available
3
4
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4,212
4,365
5,722
4,304
5,258
31,569,400
43,631,600
53,119,000
48,700,300
59,452,700
81,787
65,274
71,123
67,689
65,916
17,240,900
17,936,200
21,497,100
21,282,400
25,410,000
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
245
251
398
295
400
2,291,200
1,637,300
2,755,200
3,401,000
8,186,600
1,381
1,437
2,189
1,992
2,646
970,500
1,468,500
1,810,000
1,796,700
3,203,800
2. Saskatchewan’s numbers as of June 30, 2011.
3. This number includes estimated government funding to Regional Health Authorities (RHAs) based on total projected expenditures less non-government revenue,
as provided to Saskatchewan Health through the RHA annual operational plans.
— Acute care funding includes: acute care services, specialized hospital services, and in-hospital specialist services.
— Does not include in-patient rehabilitative care, in-patient mental health, or addiction treatment services.
— Does not include payments to Saskatchewan Cancer Agency for out-patient chemotherapy and radiation.
4. Private surgical facilities receive payments for insured services under contracts with Regional Health Authorities. The Ministry of Health does not provide payments
to these facilities.
90
Canada Health Act — Annual Report 2011–2012
Chapter 3: Saskatchewan
Insured Physician Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
1,795
1,836
1,882
1,946
1,985
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($).
585,863,285
630,253,960
651,437,652
714,441,498
794,901,943
18.Total payments for services provided by
physicians paid through fee-for-service ($).
379,456,739
14.Number of participating physicians (#).
5, 6
401,135,717
5, 6
410,875,422
5, 6
457,194,531
5, 6
457,307,474
5
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
561,415
599,106
586,621
610,328
623,778
25,442,417
27,753,524
29,037,662
31,505,813
32,103,002
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
not available
not available
not available
not available
not available
637,600
647,700
1,299,600
1,324,100
2,279,100
Insured Surgical-Dental Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
82
79
70
85
93
16,347
18,085
22,349
17,800
17,420
1,577,176
1,840,276
2,013,007
1,827,088
1,719,770
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
5. Figure is composed of fee-for-service billing and funding for the Emergency Rural Coverage Program which is paid through the fee-for-service program.
6. Figures have been revised to be consistent with the Annual Statistical Report (2007–08 to 2010–11).
Canada Health Act — Annual Report 2011–2012
91
Chapter 3: Saskatchewan
92
Canada Health Act — Annual Report 2011–2012
Chapter 3: ALBERTA
Strategy 5 – Build one health system
• As of June 24, 2011, diagnostic images could be accessed by
health care providers across Alberta through the province’s
electronic health record (EHR). This was a significant
milestone in enhancing patient care, improving patient
outcomes, and decreasing repeat exams.
1.0 PUBLIC ADMINISTRATION
Alberta
Introduction
Alberta’s Health Care System
In November 2010, the Government of Alberta released
Becoming the Best: Alberta’s 5-year Health Action Plan (Plan).
In 2011–2012, Alberta’s Ministry of Health (Health) supported the Plan’s 5 key strategies in the following ways:
1.1 Health Care Insurance Plan and
Public Authority
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 HealthLink Alberta public education campaign
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.
Strategy 2 — Provide more choice for continuing care
1.3 Audit of Accounts
Strategy 1 — Improve access and reduce wait times
helped provide more advice to patients about urgent
and emergency care options.
• Several ministries (Health, Alberta Infrastructure, Alberta
Municipal Affairs) and Alberta Health Services, Alberta’s
health authority, are working together on a Continuing
Care Implementation Plan that will address Alberta’s
future continuing care service needs.
Strategy 3 — Strengthen primary health care
• In May 2011, a new online health tool called
MyHealth.Alberta.ca was launched as part of
the Personal Health Portal initiative. The website
features approximately 9,000 health topics to connect
Albertans to trusted health care information and
services, health tools, and wellness management tips.
The website’s content was reviewed by a panel of Alberta
physicians and other health providers to ensure accuracy
and relevancy.
Strategy 4 — Be healthy, stay healthy
• The Minister’s Action on Wellness International Symposium
was held in Banff, Alberta from October 11 to 13, 2011. The
symposium approached wellness through healthy eating,
active living, mental well-being, and addiction prevention and how research findings from these areas could
be translated for practical use in Alberta.
Canada Health Act — Annual Report 2011–2012
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 March 31, 2012, and indicated
that the statements fairly represent, in all material respects, the
financial position and results of operations for the year ended
March 31, 2012.
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
In Alberta, Alberta Health Services is the body responsible
to the Minister of Health for ensuring the provision of insured
hospital services. The Hospitals Act, the Hospitalization Benefits
Regulation (AR 244/1990), the Health Care Protection Act, and
the Health Care Protection Regulation (AR 208/2000) 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: http://www.health.alberta.ca/
services/health-benefits-services.html.
93
Chapter 3: ALBERTA
During 2011–2012, 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 7,706 physicians participating under the Alberta
Health Care Insurance Plan as of March 31, 2012. Within this
6,294 physicians were paid exclusively under fee-for-service
(FFS), 738 were compensated solely under an Alternate
Relationship Plan (ARP) and the remaining 674 physicians received compensation from both FFS and ARP. Out
of the 7,706 physicians, 2,483 participated in Primary Care
Networks.
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,
94
and ensuring that each patient is advised of their opted-out
status before any service is provided to 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:
http://www.health.alberta.ca/professionals/SOMB.html.
The Schedule of Medical Benefits is revised on a regular basis. Effective March 31, 2011, many amendments
were made to the service and modifier descriptions in the
Schedule of Medical Benefits. Examples of amendments
include clarifications to the general rules, and modifiers that
affect rates pertaining to certain services. All changes to the
Schedule of Medical Benefits require Ministerial approval.
There were no new items introduced as of April 1, 2011.
Under the 2003–2011 Tri-lateral Master Agreement, any
changes to the insured physician services listed in the
Schedule of Medical Benefits were the result of negotiation
with Health, the Alberta Medical Association, and Alberta
Health Services. The Agreement expired on March 31, 2011.
There is currently no new agreement with physicians; therefore no new items have been introduced to the Schedule of
Medical Benefits after March 31, 2011, nor have any rate
increases been implemented.
2.3 Insured Surgical-Dental Services
In Alberta, a small number of surgical-dental services
are insured. The majority of dental procedures that can be
billed to the Alberta Health Care Insurance Plan can only be
performed by a dentist certified as an oral and maxillofacial
surgeon who meets the requirements stated in the Alberta
Health Care Insurance Act.
Alberta insures a number of medically necessary oral
surgical and dental procedures that are listed in the
Schedule of Oral and Maxillofacial Surgery Benefits,
available at: http://www.health.alberta.ca/professionals/
allied-services-schedule.html.
Although there is no formal agreement with dentists, 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
Canada Health Act — Annual Report 2011–2012
Chapter 3: ALBERTA
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. As of
March 31, 2012, 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: http://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.
3.0UNIVERSALITY
3.1Eligibility
Under the terms of the Alberta Health Care Insurance Act,
Alberta residents are eligible to receive publicly funded health
care services under the Alberta Health Care Insurance Plan.
A resident is defined as a person lawfully entitled to be or to
remain in Canada who makes the province his or her home
and is ordinarily present in Alberta. 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 are landed immigrants, 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.
Residents who are not eligible for coverage under the Alberta
Health Care Insurance Plan, but receive health care coverage
from the federal government, include:
• Members of the Canadian Armed Forces;
• Members of the Royal Canadian Mounted Police (RCMP)
who are appointed to a rank1; and
• Persons serving a term in a federal penitentiary.
Spouse/partner and dependants of the above are provided
with Alberta Health Care Insurance Plan coverage if they are
residing in Alberta.
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
2011–2012, no amendments were made to the legislation
regarding eligibility.
In order to access insured services under the Alberta Health
Care Insurance Plan, Alberta residents are required to register
themselves and their eligible dependants 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 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, 2012, there were 3,910,117 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, 2012, there were
216 Alberta residents who were opted-out of the Plan.
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 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.
Canada Health Act — Annual Report 2011–2012
95
Chapter 3: ALBERTA
3.2 Other Categories of Individual
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 74,046 people covered under these conditions as of
March 31, 2012.
4.0PORTABILITY
4.1 Minimum Waiting Period
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.
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 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 to help ensure timely
payments to physicians and hospitals when they provide services
to residents from other provinces/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.
In 2011–2012, no amendments were made to the legislation
regarding portability in Canada. More information on coverage during temporary absences outside Alberta is available at:
http://www.health.alberta.ca/AHCIP/outside-coverage.html.
Section 16 of the Hospitalization Benefits Regulation addresses
payment for hospital services obtained outside of Alberta but
within Canada. Section 4 of the Medical Benefits Regulation
addresses payment of physician services obtained outside of
Alberta but within Canada. These sections were not amended
in 2011–2012.
96
4.3 Coverage During Temporary Absences
Outside Canada
The Alberta Health Care Insurance Plan provides coverage to eligible Alberta residents who are temporarily absent
from Canada. A person is considered to be temporarily
absent from Alberta if the person stays outside Canada for
a period that will not exceed six consecutive months, and
the person intends to return to and maintain permanent
residence in Alberta on the conclusion of their stay outside
of Alberta.
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 Health
of their permanent and principal place of residence within
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 $461 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 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: http://www.health.alberta.ca/AHCIP/
outside-coverage.html.
Section 16 of the Hospitalization Benefits Regulation
addresses payment for hospital services obtained outside
of Canada. Section 5 of the Medical Benefits Regulation
addresses payment of physician services obtained outside
of Canada. These sections were not amended in 2011–2012.
4.4 Prior Approval Requirement
Prior approval is not required for elective insured services
received in another Canadian province/territory, except for
high-cost items not included in reciprocal agreements such
as gamma knife surgery.
Prior application is required for elective services received
out-of-country and approval may only be given through
the Out-of-Country Health Services Committee for insured
Canada Health Act — Annual Report 2011–2012
Chapter 3: ALBERTA
services that are medically required, are not experimental,
and are not available in Alberta or elsewhere in Canada.
• Wetaskiwin PCN and Vermilion PCN were launched
on September 1, 2010;
• Grande Prairie PCN was launched on October 1, 2010;
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
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.
Alberta Health Services is responsible for overseeing the
planning and delivery of health supports and services to more
than three and a half million adults and children 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.
Health announced, as part of its 2010–2013 Health Capital
Plan, funding for several ambulatory, and primary and acute
care projects designed to improve Albertans’ access to insured
health services. These projects include:
• The redevelopment of the Medicine Hat Regional Hospital
and including 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.
• A new regional hospital in Grande Prairie, which will
include a state-of-the-art cancer centre.
• The Alberta government is committed to adding
5300 continuing care spaces over the five-year period
of March 2010 to March 2015.
• The launch of seven new Primary Care Networks (PCNs)
throughout 2010–2011:
• Athabasca PCN was launched on April 1, 2010;
• Cold Lake PCN and Vegreville PCN were launched
on July 1, 2010;
Canada Health Act — Annual Report 2011–2012
and
• Lloydminster PCN was launched on January 1, 2011.
As of March 31, 2011, there were 39 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 basis. Alternate Relationship Plans (ARPs) for
specialists and family physicians offer alternative compensation
models to the fee-for-service payment system. ARPs contribute
to better health outcomes by supporting innovative health care
delivery.
Under the 2003–2011 Tri-Lateral Master Agreement that expired
on March 31, 2011, changes to physician compensation for the
provision of insured services were subject to negotiation. The
Agreement established overall increases to compensation under
the FFS and ARP compensation types. Once overall increases
were established, by virtue of the negotiated agreement, the
parties undertook an allocation process in which increases
were divided between the different medical specialties.
Under the Agreement, ARPs were established 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 enable
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. With the expiry
of the Agreement on March 31, 2011, funding for ARPs was
continued through Ministerial Order.
Beyond matters of compensation for the provision of insured
services, the 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 expired,
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Chapter 3: ALBERTA
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 negotiated agreement also provided for payments to
physicians under a physician on-call program, an office information technology program, direct overhead payments, and
rural incentive programs. Health extended funding for these
programs, as well, when the negotiated agreement expired on
March 31, 2011.
As with the majority of physicians, dentists performing
oral surgical services insured under the Alberta Health
Care Insurance Plan are compensated through the Plan on
a volume driven, fee-for-service basis. 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 population-based funding formula. A mental
health funding grant is provided for insured services provided in mental health hospitals and for community mental
health services. A funding grant is provided for insured
services in cancer hospitals and to pay for cancer services that
patients receive in regional hospitals. Hospitals in Edmonton
and Calgary receive funding to provide highly specialized
province-wide services to all Alberta residents.
Alberta’s Health Care Protection Act governs the provision of
insured surgical services performed in non-hospital surgical
98
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.
6.0 RECOGNITION GIVEN TO
FEDERAL TRANSFERS
The Government of Alberta publicly acknowledged the
federal contributions provided through the Canada Health
Transfer in its 2011–2012 publications.
Canada Health Act — Annual Report 2011–2012
Chapter 3: ALBERTA
Registered Persons
1. Number as of March 31st (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
3,473,996
3,589,494
3,692,001
3,786,238
3,910,117
Insured Hospital Services Within Own Province or Territory
Public Facilities 1
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
204
251
248
250
250
not available
not available
not available
not available
not avaialable
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4. Number of private for-profit facilities
providing insured health services (#).
not available
not available
not available
not available
not available
5. Payments to private for-profit facilities
for insured health services ($).
not available
not available
not available
not available
not available
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
5,334
5,447
5,411
5,689
5,707
27,481,524
31,475,940
33,077,528
37,887,391
36,659,355
101,455
104,127
105,792
110,757
109,703
18,004,246
25,346,678
26,879,756
29,382,381
29,687,993
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada2
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
4,014
4,762
4,506
3,075
3,613
3
378,043
446,718
425,269
294,509
339,343
3
3,934
4,305
4,544
3,425
4,414
3
214,162
291,836
306,639
267,120
467,081
3
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
2. These data do not include claims/payments for Alberta residents who have received health services out of country through the Out-of-Country Health Services
Committee application process.
3. Data reported for out of country hospital and physician services is accurate as of March 31, 2012, but does not reflect claims still being processes for 2011–2012.
Canada Health Act — Annual Report 2011–2012
99
Chapter 3: ALBERTA
Insured Physician Services Within Own Province or Territory
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of non-participating physicians (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
6,058
6,266
6,482
6,743
7,706
not applicable
5
not applicable
5
not applicable
5
not applicable
5
4
0
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($).
not available
not available
not available
not available
not available
18.Total payments for services provided by
physicians paid through fee-for-service ($).
1,718,717,023
1,851,703,042
2,133,199,354
2,302,481,210
2,450,159,476
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
548,423
696,639
599,596
611,503
616,786
20,899,683
22,614,491
24,621,807
25,340,583
27,960,901
not available
7
not available
7
Insured Physician Services Provided Outside Canada6
21.Number of services (#).
22.Total payments ($).
22,055
22,817
22,070
15,654
1,105,831
1,245,840
1,266,451
909,715
7
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
207
202
212
207
218
16,769
18,705
18,963
21,052
20,784
3,913,975
4,479,725
4,847,467
5,747,026
6,293,750
4. 6,294 of these are paid under fee for service (FFS), 738 under and Alternative Relationship Plan (ARP) and the remaining 674 received compensation from both FFS and ARP.
5. 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. As of March 31, 2012 there were zero non-participating physicians in Alberta, as noted in indicator 16.
6. 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.
7. Data for out of country hospital and physician services is still being processed for 2011–2012.
100
Canada Health Act — Annual Report 2011–2012
Chapter 3: British Columbia
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
British Columbia
Introduction
British Columbia has a progressive and integrated health
system that includes insured services funded under the
Canada Health Act, services funded wholly or partially by
the Government of British Columbia and services regulated,
but not funded, by government. The Ministry of Health
(the Ministry) has overall responsibility for ensuring that
quality, appropriate, and timely health services are available
to all British Columbians.
The Ministry works with health authorities, care providers, agencies, and other groups to guide and enhance the
province’s health services, provide access to care, and ensure
British Columbians are supported in their efforts to maintain
and improve their health. The Ministry provides leadership,
direction, and support to these service delivery partners and
sets province-wide goals, standards, and expectations for
health service delivery by health authorities. The province’s six
health authorities are the organizations primarily responsible
for health service delivery. 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 2011–2012
Annual Service Plan Report: www.bcbudget.gov.bc.ca/
Annual_Reports/2011_2012/pdf/hlth.pdf.
Canada Health Act — Annual Report 2011–2012
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 2011–2012, the Medicare Protection Act was amended to
support the introduction of a more secure care card, designed
to improve patient safety and reduce fraud. Further, the
Medical and Health Care Services Regulation was amended
to bring into force this amendment to the Medicare Protection
Act and to detail the framework of the requirement for
enrolment and renewal of enrolment in MSP.
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.
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Chapter 3: British Columbia
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:
• Vital Statistics Annual Report;
• Provincial Health Officer’s Annual Report (on the health
of the population);
• Canadian Institute for Health Information reports; and
• Medical Services Commission Annual Report.
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.
• The Office of the Auditor General (OAG) of British
Columbia is responsible for conducting annual audits
as well as special audits/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: http://www.bcauditor.com/pubs/2012/special/
auditor-generals-opinions-summary-financial-statements-an.
The OAG’s special audits/reports can be located at the
following link: http://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 2011–2012 fiscal year.
102
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, retains control of, and
performs 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.
• 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.
2.0Comprehensiveness
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.
Canada Health Act — Annual Report 2011–2012
Chapter 3: British Columbia
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 or midwife.
There is no scheduled or regular process to review insured
hospital services, as the insured services included in the
regulations are intended to be comprehensive/inclusive.
Uninsured services are referred to in Section 2.4 of this
report.
When medically required, the following are provided to
beneficiaries who are in-patients in an acute or rehabilitation
hospital:
• accommodation and meals at the standard level;
• necessary nursing service;
• drugs, biologicals, and related preparations which are
required by the patient and administered in hospital;
• laboratory and radiological procedures and related
interpretations;
• diagnostic procedures and the necessary interpretations,
as approved by the Minister;
• use of operating room, caseroom, anaesthetic facilities,
routine surgical supplies, and other necessary equipment
and supplies;
•
•
•
•
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 services 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.
Canada Health Act — Annual Report 2011–2012
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/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.
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 2011–2012, 9,628 physicians were enrolled with
MSP and billed fee-for-service (FFS) (includes only general practitioners and medical specialists who billed FFS in
2011–2012). 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
enrol 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,
103
Chapter 3: British Columbia
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.
A physician may choose not to enrol or to de-enrol with the
Medical Services Commission (MSC). Enrolled physicians
may cancel their enrolment by giving 30 days written notice
to the MSC. Patients are responsible for the full cost of services
provided by non-enrolled physicians. In 2011–2012, MSP had
5 opted-out physicians. Based on reclassification of information
and corresponding data, British Columbia does not track nonparticipating physicians.
Enrolled physicians can elect to be paid directly by patients
by giving written notice to the MSC. The MSC will specify the
effective date between 30 and 45 days following receipt of the
notice. In this case, patients may apply to MSP for reimbursement of the fee for insured services rendered.
Under the Physician Master Agreement between the government, the MSC, and the British Columbia Medical Association
(BCMA), modifications to the Payment Schedule 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 2011–2012, physician services which were
added as MSP insured benefits included 106 new fee items
which reflect current practice standards, for example: 34 new
fee items were in the Section of General Surgery; 21 new fee
items were in the Section of General Practice; and eight new
fee items were in the Section of Plastic surgery.
2.3 Insured Surgical-Dental Services
Surgical-dental services are covered by the Medical Services
Plan (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 surgicaldental 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
104
may provide insured surgical-dental services in hospital.
There were 218 dentists enrolled with MSP and billing FFS
in 2011–2012 (includes only oral surgeons, dental surgeons,
oral medicine, and orthodontists).
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, 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; tele­
visions, telephones, and private nursing services; and dental
care that could safely be provided in a dental office including
prosthetic and orthodontic services. Insured hospital services
do not include transportation between place of residence
and hospital (however, health authorities are required to
fund some of these services by Ministry policy, with a small
user charge).
Services not insured under 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.
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.”
Canada Health Act — Annual Report 2011–2012
Chapter 3: British Columbia
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 2011–2012, 11 obsolete fee items were removed from the
Fee Schedule. The fee items removed were from the Section of
the General Surgery for procedures which are now obsolete.
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 RCMP and the Canadian Forces, and to those returning
from an overseas tour of duty, as well as to released inmates
of federal penitentiaries.
The number of residents registered with MSP as of March 31,
2012, was 4,565,864.
3.2 Other Categories of Individual
3.0Universality
3.1Eligibility
Section 7 of the Medicare Protection Act (MPA) defines the
eligibility and enrolment of beneficiaries for insured services.
Under the MPA, Part 2 of the Medical and Health Care Services
Regulation details residency requirements. A person must be
a resident of British Columbia to qualify for provincial health
care benefits.
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;
• is physically present in British Columbia at least
six months in a calendar year; and
• is deemed under the regulations to be a resident.
Certain other individuals, such as some holders of permits issued
under the federal Immigration and Refugee Protection Act are
deemed to be residents (see Section 3.2 of this report), but this
does not include a tourist or visitor to British Columbia.
New residents or persons re-establishing residence in British
Columbia are eligible for coverage after completing a waiting
period that normally consists of the balance of the month 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.
All residents are entitled to hospital and medical care insurance
coverage. Those residents who are members of the Canadian
Forces, appointed members of the Royal Canadian Mounted
Police (RCMP)1, or serving a term of imprisonment in a
Holders of Minister’s Permits, Temporary Resident Permits,
study permits, and work permits 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.
3.3Premiums
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, 2012, are $64.00 for one person, $116.00
for a family of two, and $128.00 for a family of three or more.
Residents with limited incomes may be eligible for premium
assistance. There are five levels of assistance, ranging from
20 to 100 percent of the full premium. Premium assistance is
available only to beneficiaries who, for the last 12 consecutive
months, have resided in Canada and are either a Canadian
citizen or a holder of permanent resident (landed immigrant)
status under the federal Immigration and Refugee Protection Act.
4.0Portability
4.1 Minimum Waiting Period
New residents or persons re-establishing residence in British
Columbia are eligible for coverage after completing a waiting
period that normally consists of the balance of the month of
1. Although outside the 2011–12 fiscal year reporting period, for clarity purposes Health Canada notes that “On June 29, 2012, as a result of the federal Bill C-38, now the 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.”
Canada Health Act — Annual Report 2011–2012
105
Chapter 3: British Columbia
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.
New residents from other parts of Canada are advised to
maintain coverage with their former medical plan during
the waiting period.
4.2 Coverage during Temporary Absences
in Canada
Sections 3, 4 and 5 of the Medical and Health Care Services
Regulation of the Medicare Protection Act define portability
provisions for persons temporarily absent from British
Columbia with regard to insured services. In 2011–2012,
there were no amendments to the Medical and Health Care
Services Regulation with respect to portability provisions.
Individuals leaving the province temporarily on extended
vacations, or for temporary employment, may be eligible
for coverage for up to 24 months. Approval is limited to once
in five years for absences exceeding six months in a calendar
year. 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. When
a beneficiary stays outside British Columbia longer than the
approved period, they will be required to fulfill a waiting
period upon returning to 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. 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.
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.
106
British Columbia pays host provincial rates for insured
services according to rates established by the Interprovincial
Health Insurance Agreements Coordinating Committee.
4.3 Coverage During Temporary Absences
Outside Canada
The 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.
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 are in full-time
attendance at a recognized educational facility and are
enrolled in a program which leads to a degree or certificate
recognized in Canada. Generally, beneficiaries who have
been studying outside of BC 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, and who has been away
for less than 24 months, 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.
However, because of the increasing demand for a specialized
and mobile work force employed for short-term contracts and
assignments, exceptions may be made to enable coverage for
up to 24 consecutive months of absence while temporarily
outside British Columbia. Approval is limited to once in
five years for absences that exceed six months in a calendar
year. In addition, 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 for approval
to maintain their eligibility.
British Columbia residents who are temporarily absent
from British Columbia and cannot return due to extenuating
health circumstances are deemed residents for 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 elective procedures that are
covered under the interprovincial reciprocal agreements with
other provinces. Prior approval from the Medical Services
Canada Health Act — Annual Report 2011–2012
Chapter 3: British Columbia
Commission (MSC) is required for procedures that are not
covered under the reciprocal agreements.
The physician services excluded under the Interprovincial
Agreements for the Reciprocal Processing of Out-of-Province
Medical Claims are: surgery for alteration of appearance
(cosmetic surgery); gender reassignment surgery; surgery for
reversal of sterilization; therapeutic abortions; routine periodic
health examinations including routine eye examinations; in
vitro fertilization, artificial insemination; acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS),
moxibustion, biofeedback, hypnotherapy; services to persons
covered by other agencies (e.g., RCMP, 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-forprofit residential facilities) may require the recommendation of
the Health Authorities Division 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 Physician and Dental-Surgical Services
Access to insured services continues to be enhanced:
• The Ministry provides funding through the Medical
On-Call Availability Program to health authorities to
enable them to contract with groups of physicians to
provide “on-call” coverage necessary for hospitals to
deliver emergency health care services to unassigned
patients in a reliable, effective, and efficient manner.
• The Ministry continued and implemented several
programs under the 2002 Subsidiary Agreement for
Physicians in Rural Practice, 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 is
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 general practitioners 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 56 small communities to
attend continuing medical education and also provided
vacation relief.
• Rural Specialist Locum Program — assists rural
specialists in taking vacations and continuing medical education by providing paid locum support. The
program provided locum support for core specialists
in 10 rural communities to provide vacation relief and
assistance while physician recruitment efforts were
underway.
• In 2011–2012, approximately 3,000 general practitioners
• Rural Emergency Enhancement Fund — provides
• The Full-Service Family Practice Incentive Program has
• Rural Education Action Plan — supports the training
(GPs) and specialists received all or part of their income
through British Columbia’s Alternative Payments Program
(APP). APP funds regional health authorities to contract with
or hire physicians, in order to deliver insured clinical services.
been 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.
Canada Health Act — Annual Report 2011–2012
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.
needs of physicians in rural practice through several
components, including rural practice experience for
medical students and enhanced skills for practicing
physicians.
107
Chapter 3: British Columbia
• Rural Continuing Medical Education — offers eli-
gible 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.
• Recruitment Incentive Fund — provides an incentive 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, Victoria, Abbotsford, Vancouver, Prince George,
Vernon, Kelowna, Courtenay/Comox, Campbell River, and
Fort St. John, 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). As
of March 31, 2012 (the fiscal year deadline for the 2011–2012
Canada Health Act report submission), the province and the
BCMA were in negotiations regarding the ratification of the
renewal of the PMA2.
In general terms, the PMA provides the framework for man­
aging the ongoing relationship between the government,
health authorities, physicians, and the BCMA. Its Subsidiary
Agreements provide additional detail related to:
• Physician benefits (the Benefits Subsidiary Agreement) —
outlines programs that provide contractually negotiated
benefits.
• Rural programs (the Rural Practice Subsidiary Agreement) —
provides financial incentives for physicians to locate to and
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.
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 a 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.
Dentists are licensed under the Health Professions Act. The
province and the British Columbia Dental Association
(BCDA) negotiated a Memorandum of Understanding in
2. Although outside the scope of the 2011/12 fiscal year reporting period, British Columbia notes that in July 2012, doctors in BC ratified a new four-year agreement that will
support ongoing efforts to recruit and retain physicians, while also improving access to specialists and care in rural and remote communities. For further information, please
see the Government of British Columbia News Release: http://www2.news.gov.bc.ca/news_releases_2009-2013/2012HLTH0077-001081.htm
108
Canada Health Act — Annual Report 2011–2012
Chapter 3: British Columbia
2010 that is effective through March 2012 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 Medical Services Plan to individual
physicians, based on submitted claims, and through the
Alternative Payment Program (APP) to health authorities
for physicians’ services. In 2011–2012, over 73 percent of
medical expenditures were distributed as fee-for-service and
11 percent were distributed as alternative payments. Of the
alternative payments, 78 percent were distributed through
contracts, 20 percent as sessions (3.5-hour units of service),
and two 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 regional health
authorities. This funding allocation is to be used to fund
the full range of necessary health serviczes 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 govern payments made by the health care plan
to health authorities. This statute establishes the authority of
the Minister to make payments to hospitals, and specifies in
broad terms what services are insured when provided within
a hospital.
The hospitals’ portion of the funding allocation is not specified; however, the exception to this rule is funding targeted
for specific priority projects (e.g., reduction in wait times for
hips and knees, and patient-focused funding). For these types
of initiatives, funding is provided to health authorities rather
than hospitals and it is specifically earmarked and must be
reported on separately.
The Ministry of Health introduced patient-focused funding
in 2010–2011 under which a significant portion of eligible
acute care funding is based on actual workload performed.
The Ministry continued the Patient-Focused Funding (PFF)
initiative in 2011–2012 and health authorities participated
in the PFF initiatives, such as Emergency Department Payfor-Performance; Procedural Care Programs (e.g., Magnetic
Canada Health Act — Annual Report 2011–2012
Resource Imaging); Community Programs; Activity Based
Funding; and National Surgical Quality Improvement.
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.
Insured hospital services are included within the annual
funding allocations to health authorities, as well as specific
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.
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 2011–2012, 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).
6.0 Recognition Given to
Federal Transfers
Funding provided by the federal government through the
Canada Health Transfer is recognized and reported by the
Government of British Columbia through various government websites and provincial government documents. In
2011–2012, these documents included:
• Estimates, Fiscal Year Ending March 31, 2012,
available at: http://www.bcbudget.gov.bc.ca/2012/
estimates/2012_Estimates.pdf.
• 2011–2012 Budget and Fiscal Plan, which
includes the 2011–2012 Third Quarterly Report,
available at: http://www.bcbudget.gov.bc.ca/2011/
bfp/2011_Budget_Fiscal_Plan.pdf.
• Public Accounts 2011–2012, available at:
http://www.fin.gov.bc.ca/ocg/pa/11_12/Pa11_12.htm.
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Chapter 3: British Columbia
Registered Persons
1. Number as of March 31st (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4,335,676
4,402,540
4,469,177
4,521,503
4,565,864
2010–2011
2011–2012
Insured Hospital Services Within Own Province or Territory
Public Facilities
2007–2008
120
2. Number (#). 3
3. Payments for insured health services ($). 4
2008–2009
3
119
2009–2010
3
119
119
3
120
3
not available
not available
not available
not available
not available
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
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 ($).
not available
not available
not available
not available
not available
Private For-Profit Facilities
3
Insured Hospital Services Provided to residents in another province or territory
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
7,160
7,102
6,846
5,909
6,551
55,309,733
64,550,692
64,655,739
67,078,612
69,785,313
95,677
95,326
87,948
78,075
86,544
19,088,368
24,262,195
24,188,890
21,830,298
25,327,347
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
1,603
1,963
3,056
2,469
2,961
14,486,341 11,811,654
6,058,867
4,452,628
4,152,060
1,215
1,630
1,920
1,940
2,468
553,661
967,704
1,174,112
999,733
1,301,179
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.
3. As per the guidelines, the number of public facilities in this table excludes psychiatric hospitals and extended care facilities.
4. 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 and $9.7 billion in 2011–2012.
110
Canada Health Act — Annual Report 2011–2012
Chapter 3: British Columbia
Insured Physician Services Within Own Province or Territory
2007–2008
14.Number of participating physicians
as of March 31st (#).
8,772
2008–2009
5
8,986
2009–2010
5
9,201
2010–2011
5
9,417
15.Number of opted-out physicians
as of March 31st (#).
5
5
5
5
16.Number of not participating physicians
as of March 31st (#).
2
2
2
not available
not available
not available
not available
not available
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
2,234,652,895
7
2,334,513,866
7
2,460,935,638
7
2,541,874,909
2011–2012
9,628
5
5
5
6
not available
6
not available
7
2,619,943,719
7
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
725,130
736,007
622,390
626,034
651,682
26,465,248
28,703,587
29,591,918
30,779,981
32,421,561
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
84,204
82,654
75,909
82,076
66,506
4,379,977
4,528,521
4,014,813
4,119,511
3,592,313
Insured Surgical-Dental Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
245
249
243
236
218
43,262
46,736
50,341
51,036
52,047
6,305,343
7,289,302
8,093,266
7,991,262
8,130,009
23.Number of participating dentists
as of March 31st (#).
24.Number of services provided as
of March 31st (#).
25.Total payments as of March 31st ($).
5. The number of participating physicians in item 14 is for physicians who received payments through Fee-For-Service.
6. Based on reclassification of information and corresponding data, BC does not track non-participating physicians. Data for item number 16 is not available.
7. The MSP Fee-For-Service payments in item 18 are restated to include medical services referred to medical practitioners by midwives or nurse practitioners.
Canada Health Act — Annual Report 2011–2012
111
112
Canada Health Act — Annual Report 2011–2012
Chapter 3: Yukon
In 2010, the Yukon government introduced a motion to
develop a Wellness Strategy to promote healthy living habits
for all Yukoners. This strategy will focus on children and youth,
healthy aging, and social inclusion, with the goal of improving
overall health outcomes and reducing health disparities.
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 here­
after 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 February 2009, the Yukon government launched a four-year
Licensed Practical Nurse (LPN) program at Yukon College to
encourage Northerners who are interested in pursuing a career
in a medical profession to remain in Yukon. Training LPNs
locally is helping address Yukon’s demand for health care
professionals, particularly in continuing care and home care.
Canada Health Act — Annual Report 2011–2012
The Yukon Hospital Corporation is investing approximately
$70 million for three major infrastructure projects: the
now completed Crocus Ridge Place, which is a residence
for visiting health care professionals and staff office complex
in Whitehorse; and the construction of two new Regional
Hospitals in Dawson City (anticipated opening is Spring 2013)
and Watson Lake (anticipated opening is Spring 2013).
The Yukon government is also utilizing 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 Telehealth video conferencing equipment capabilities within the
First Nations health offices.
The Department of Health and Social Services introduced the
Weight Wise program to the territory in the Fall of 2010. A local
physician and nurse were trained to deliver the program by
Alberta Health Services, which also provides the 10 module reeducation program to its obese clients. In 2012, a psychologist
was added to support clients as they navigate the weight wise
program. The program is designed to help clients achieve a
healthy weight in order to reduce medical complications for the
client and reduce potential costs to the healthcare system. Since
the introduction, Yukon has extended an intake for 15 clients
every six month. To date, 95 clients have participated in the
program and an additional 101 are currently wait listed.
Finally, Yukon established a Referred Care Clinic to support a
number of complex “orphan” patients who are without the services of a family physician (general care needs) and who may
also present with compounding addictions, pain management
or mental health care needs. Historically, this patient group
has relied on the Whitehorse General Hospital Emergency
Department (WGH ER) to meet their care needs resulting in
growing pressure on the sole acute care facility in Whitehorse.
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 2011–2012.
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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 2011–2012.
• conduct surveys and research programs and obtain statis-
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:
• prescribe the forms and records necessary to carry out the
• develop and administer the Plan;
• determine eligibility for entitlement to insured health
services;
tics for those purposes;
• appoint inspectors and auditors to examine and obtain
information from hospital records, reports, and accounts;
provisions of the Act; and
• perform any other functions and discharge any other
duties assigned to the administrator by the Regulations.
1.2 Reporting Relationship
• register persons in the Plan;
• make payments under the Plan, including the determination
The Department of Health and Social Services is accountable
to the Legislative Assembly and the Government of Yukon
through the Minister.
• determine the amounts payable for insured health services
• establish what information is required to be provided
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 last Annual Report
presented by the Director of Insured Health and Hearing
Services to the Minister of Health and Social Services was for
the 2010–2011fiscal year. The 2012–2013 Annual Report will
be provided in the fall of 2013.
• appoint inspectors and auditors to examine and obtain
1.3 Audit of Accounts
of eligibility and amounts;
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;
under the Act and the form that information must take;
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;
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 30 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.
Regarding the Yukon Hospital Corporation, section 13(2)
of the Hospital Act requires every hospital to submit a
report of the operations of the Corporation for that fiscal
year; the report is to include the financial statements of the
Corporation and the auditor’s report. The report is to be
provided to the Department of Health and Social Services
within six months of the end of each fiscal year.
• approve hospitals for the purposes of the Act;
114
Canada Health Act — Annual Report 2011–2012
Chapter 3: Yukon
2.0COMPREHENSIVENESS
2.1 Insured Hospital Services
The Hospital Insurance Services Act, sections 3, 4, 5 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 2011–2012.
In 2011–2012, 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 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
Canada Health Act — Annual Report 2011–2012
preparations as provided in Schedule B of the regulations,
when administered in the hospital; use of operating room,
case room and anaesthetic facilities, including necessary
equipment and supplies; routine surgical supplies; use of
radiotherapy facilities where available; use of physiotherapy
facilities where available; and services rendered by persons
who receive remuneration 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 diagnostic 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 inpatient 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.
Similar to the 2010–2011 fiscal year, the Government of Yukon
continues to provide additional funds to assist patients with
recourse options who have orthopaedic (knees and hip) or
ophthalmology surgery requirements.
In addition, 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.
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Chapter 3: Yukon
2.2 Insured Physician Services
2.3 Insured Surgical-Dental 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 2011–2012.
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.
The Yukon Health Care Insurance Plan covers physicians
providing medically required services. In order to participate
in the Yukon Health Care Insurance Plan, physicians must:
• register for licensure pursuant to the Health Professions
Act; and
• maintain licensure, pursuant to the Health Professions Act.
The number of resident physicians participating in the Yukon
Health Care Insurance Plan in 2011–2012 was 74.
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 2011–2012, no physicians provided
written notice of their election to collect fees other than from the
Yukon Health Care Insurance Plan.
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.
116
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
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 2011–2012.
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 non-exhaustive 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
Canada Health Act — Annual Report 2011–2012
Chapter 3: Yukon
or writing prescriptions; the supply of drugs; dental care
except procedures listed in Schedule B; and experimental
procedures.
• Surgical-dental services — an amendment by Order-In-
Council to Schedule B of the Health Care Insurance Plan
Regulations is required. A service could be de-insured
if determined not medically necessary or is no longer
required to be carried out in a hospital under general
anaesthesia. The Director, Insured Health and Hearing
Services, manages this process. No surgical-dental services
were de-insured in 2011–2012.
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 non-insured
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, Insured Health and
Hearing Services, to monitor usage and service concerns.
Physicians in Yukon may bill patients directly for non-insured
services. Block fees are not used at this time; however, some
do bill by service item. Billable services include, but are not
limited to: completion of employment forms; medical-legal
reports; transferring records; third-party examinations;
some elective services; and telephone prescriptions, advice or
counselling. 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 deinsure a service, all physicians are notified in writing. The
Director, Insured Health and Hearing Services, manages
this process. No services were removed in 2011–2012.
• 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, 2012, 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.
Canada Health Act — Annual Report 2011–2012
3.0UNIVERSALITY
3.1Eligibility
Eligibility requirements for insured health services are set
out in the Health Care Insurance Plan Act and regulations,
sections 2 and 4 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 2011–2012. Subject to the provisions of these Acts and
regulations, every Yukon resident is eligible for and entitled
to insured health services on uniform terms and conditions. The term “resident” is defined using the wording of
the Canada Health Act and means a person lawfully entitled
to be or to remain in Canada, who makes his or her home and
is ordinarily present in Yukon, but does not include a tourist,
transient or visitor. 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 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.
117
Chapter 3: Yukon
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, 2012 was 36,694.
3.2 Other Categories of Individual
The Yukon Health Care Insurance Plan provides health
care coverage for other categories of individuals, as follows:
• Returning Canadians — waiting period is applied
• Permanent Residents — waiting period is applied
• Minister’s Permit — waiting period is applied, if
authorized
• Foreign Workers — waiting period is applied, if holding
Employment Authorization
• Clergy — waiting period is applied, if holding
Employment Authorization
Employment Authorizations must be in excess of 12 months.
4.0PORTABILITY
4.1 Minimum Waiting Period
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 entitled to coverage are required to complete the
minimum waiting period with the exception of children
adopted by insured persons (see section 3.1), and newborns.
4.2 Coverage During Temporary Absences
in Canada
The provisions relating to portability of health care insurance
during temporary absences outside Yukon, but within Canada,
are defined in sections 5, 6, 7 and 10 of the Yukon Health Care
Insurance Plan Regulations and sections 6, 7(1), 7(2) and 9 of
the Yukon Hospital Insurance Services Regulations.
118
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 of
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 2011–2012.
The 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
the medical reciprocal billing arrangement. Persons receiving
medical (physician) services in Quebec may be required to pay
directly and submit claims to the Yukon Health Care Insurance
Plan for reimbursement.
The Hospital Reciprocal Billing Agreements provide for payment of insured in-patient and out-patient hospital services
to eligible residents receiving insured services outside Yukon,
but within Canada.
The Medical Reciprocal Billing Agreements provide for
payment of insured physician services on behalf of eligible
residents receiving insured services outside Yukon, but
within Canada. Payment is made to the host province at
the rates established by that province.
Insured services provided to Yukon residents while temporarily
absent from the territory, are paid at the rates established by the
host province.
Canada Health Act — Annual Report 2011–2012
Chapter 3: Yukon
4.3 Coverage During Temporary Absences
Outside Canada
and are not impeded by financial or other barriers. There is no
extra-billing in the Yukon for any services covered by the Plan.
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.
Access to hospital or physician services not available locally
are provided through the Visiting Specialist Program, Telehealth Program or the Travel for Medical Treatment Program.
These programs ensure that there is minimal or no delay in
receiving medically necessary services.
No amendments were made to these sections of the legislation
in 2011–2012. 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.”
To improve access to insured health services, the number
of visiting specialists was increased to better serve patients
in the territory. The Department has also provided Yukon
women better access to obstetric services through the newly
established Women’s Clinic.
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.
5.2 Physician Compensation
The provisions for portability of health insurance during
out-of-country absences for students, temporary workers
and missionaries are the same as for absences within Canada
(see section 4.2 of this report).
Insured physician services provided to eligible Yukon
residents temporarily outside the country are paid at rates
equivalent to those paid had the service been provided in
Yukon. Reimbursement is made to the insured person by
the Yukon Health Care Insurance Plan or directly to the
provider of the insured service.
Insured in-patient hospital services provided to eligible
Yukon residents outside Canada are paid at the rate established in the Standard Ward Rates Regulation for the
Whitehorse General Hospital.
Insured out-patient hospital services provided to eligible
Yukon residents outside Canada are paid at the rate established in the Charges for Out-Patient Procedures Regulation.
4.4 Prior Approval Requirement
There is no legislated requirement that eligible residents must
seek prior approval before seeking elective or emergency hospital or physician services outside Yukon or outside Canada.
5.0ACCESSIBILITY
5.1 Access to Insured Health Services
There are no user fees or co-insurance charges under the Yukon
Health Care Insurance Plan or the Yukon Hospital Insurance
Services Plan. All services are provided on a uniform basis
Canada Health Act — Annual Report 2011–2012
The Department of Health and Social Services seeks its
negotiating mandate from the Government of Yukon,
before entering into negotiations with the Yukon Medical
Association (YMA). The YMA and the government each
appoint members to the negotiating team. Meetings are
held as required until an agreement has been reached. The
YMA’s negotiating team then seeks approval of the tentative
agreement from the YMA membership. The Department
seeks ratification of the agreement from the Government of
Yukon. The final agreement is signed with the concurrence
of both parties.
The 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 2011–2012.
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
119
Chapter 3: Yukon
hospital to submit requests for additional funding assistance
for implementing new or enhanced programs.
Only the Whitehorse General Hospital is funded directly
through a contribution agreement. The Watson Lake Cottage
Hospital and all health centres are funded through the
Government of Yukon budget process.
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 2011–2012.
120
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 2011–2012 annual Main Estimates and Public Accounts
publications, which are available publicly. Section 3(1)(d) and
(e) of the Health Care Insurance Plan Act and section 3 of the
Hospital Insurance Services Act acknowledge the contribution
of the Government of Canada.
Canada Health Act — Annual Report 2011–2012
Chapter 3: Yukon
Registered Persons
1. Number as of March 31st (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
33,423
33,983
35,084
36,063
36,694
Insured Hospital Services Within Own Province or Territory
Public Facilities 1
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
15
15
15
15
15
3. Payments for insured health services ($).2
44,573,638
49,051,490
51,734,000
57,655,576
58,943,422
Private For-Profit Facilities
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4. Number of private for-profit facilities
providing insured health services (#).
0
0
0
0
0
5. Payments to private for-profit facilities
for insured health services ($).
0
0
0
0
0
2. Number (#).
Insured Hospital Services Provided to residents in another province or territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
976
1,013
956
1,047
996
10,742,393
11,183,888
15,333,983
16,583,657
13,507,016
9,027
9,983
12,830
13,197
13,550
2,155,225
2,888,247
3,248,555
3,413,932
3,974,870
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($). 3
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
15
13
19
25
20
32,075
12,003
67,671
45,893
100,716
74
40
92
74
77
11,782
8,233
18,862
12,741
21,950
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
1. Public facilities are the 13 health centres (Beaver Creek, Destruction Bay, Carcross, Carmacks, Dawson, Faro, Haines Junction, Mayo, Old Crow, Pelly Crossing,
Ross River, Teslin and Whitehorse) and 2 hospitals (Whitehorse and Watson Lake).
2. Includes monies paid to hospitals and community nursing stations
3. Hospitals have up to a year from date of service to bill jurisdictions. (information is based upon date of service; therefore, 2011–12 reporting period is still open
until March 31, 2013)
Canada Health Act — Annual Report 2011–2012
121
Chapter 3: Yukon
Insured Physician Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
67
67
69
69
74
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
17. Total payments for services provided
by physicians paid through all payment
methods ($).
16,342,282
19,139,117
20,781,850
21,549,640
22,387,839
18.Total payments for services provided by
physicians paid through fee-for-service ($).4
14,127,399
16,294,365
17,719,117
17,701,880
18,373,627
14.Number of participating physicians (#).
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
38,512
45,744
50,893
54,007
53,915
1,977,052
2,297,501
3,008,828
3,185,612
3,219,166
Insured Physician Services Provided Outside Canada
21.Number of services (#).
not available
not available
not available
not available
not available
22.Total payments ($).
not available
not available
not available
not available
not available
Insured Surgical-Dental Services Within Own Province or Territory 5
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
23.Number of participating dentists (#).
3
4
4
2
3
24.Number of services provided (#).
4
23
4
4
14
4,433
25,602
6,271
4,631
13,913
25.Total payments ($).
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.
122
Canada Health Act — Annual Report 2011–2012
Chapter 3: Northwest Territories
• In 2011–2012, work was done to amend the Long Term
Care fee prescribed in the Hospital Insurance Regulations
under the Hospital Insurance and Health and Social
Services Administration Act to adjust for inflation. Work
had also begun on a long term solution to establish a
Long Term Care rate that could be adjusted for inflation
without further amendment to the Regulations.
More information on the Department’s legislative initiatives
is available in the Health and Social Services Annual Report,
released in the fall of 2012.
Northwest
Territories
Introduction
The Department of Health and Social Services (the Department)
along with six regional Health and Social Service Authorities, the
Tlicho Community Services Agency and the Stanton Territorial
Health Authority, plan, manage, deliver and evaluate a full
repertoire of health and social services at both the community
and facility level throughout the Northwest Territories.
During the 2011–2012 fiscal year the Department carried out
the following activities:
• All extended health benefits are now provided through
Alberta Blue Cross. During the previous fiscal year some
extended health benefits were provided by Alberta Blue
Cross and others were provided directly through the
Department of Health and Social Services.
1.0 Public Administration
1.1 Health Care Insurance Plan
and Public Authority
The Northwest Territories Health Care Plan consists of the
Medical Care Plan and the Hospital Insurance Plan. The
Medical Care Plan is administered by the public authority
of the Director of Medical Insurance, as appointed by the
Minister of Health and Social Services (hereafter referred to
as the Minister) under the Medical Care Act. The Minister
administers the Hospital Insurance Plan through each Health
and Social Service Authorities’ board of management as per
section 10 of the Hospital Insurance and Health and Social
Services Administration Act (HIHSSA). Legislation that
enables the Health Care Insurance Plan within the NWT
includes the Medical Care Act and the HIHSSA.
1.2 Reporting Relationship
• A new Health Information Act is being drafted. This new
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 full repertoire of health and
social services at both the community and facility level
throughout the NWT.
• A new Health and Social Services Professions Act is being
The Minister appoints the Director of Medical Insurance who
is responsible for administering the Medical Care Act and its
regulations. The Director reports to the Minister any matters
concerning the operational status of the Medical Care Plan.
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 pharmacies. This will include standards for consent
and notice, provisions for access for research and system
planning, as well as information systems management.
developed. This 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.
Canada Health Act — Annual Report 2011–2012
The Minister, through the Boards of Management, administers
the Hospital Insurance Plan. Each HSSA is administered by a
Minister appointed Board of Management. The Boards manage, control and operate health and social services within the
current parameters, resources and policies. Board members
serve for three years, with exception of the chairperson whose
term is indeterminate.
123
Chapter 3: Northwest Territories
The TCSA has a Board in which each Tlicho community is
represented by one appointed person who may serve a tenure
of up to four years. The chairperson on the Board is appointed
by the Minister of Aboriginal Affairs and Intergovernmental
Relations in consultation with the members appointed by each
community government. The Minister of Aboriginal Affairs
and Intergovernmental Relations decides and fixes the length
of the chairperson’s term.
Insured out-patient hospital services include:
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.
• psychiatric and psychological services under an approved
1.3 Audit of Accounts
As part of the Government of the Northwest Territories
annual audit, the Office of the Auditor General of Canada
audits payments under the Hospital Insurance Plan and the
Medical Care Plan.
2.0 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 4 hospitals and 23 health
centers 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 prescribed by
a physician;
• 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.
124
• laboratory tests;
• diagnostic imaging (including interpretations when needed);
• physiotherapy, speech and language pathology therapy
and occupational therapy;
• minor medical and surgical procedures and related
supplies; and
hospital program.
Travel assistance is provided for residents who require medically
necessary procedures that are not offered in their community
or elsewhere within the NWT. Medical Travel Assistance (as
outlined in the Medical Travel Policy) provides barrier free access
to care services and procedures for the residents of the NWT
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 NWT residents insurance for physician services. Physicians, nurse practitioners and midwives
provide insured services under the Medical Profession Act,
Nursing Profession Act and the Midwifery Act, respectively; all
of whom are required by legislation to be licensed to practise
in the NWT. As of March 31, 2012, there were 285 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 are no opted-out physicians in
the NWT.
The Medical Care Plan insures all medically necessary physician
services such as:
•
•
•
•
•
diagnostics and therapeutics;
surgical supplies and services;
eye examinations provided by a licensed ophthalmologist;
obstetrics; and
specialist visits with proper approval from a medical
practitioner.
The Director of Medical Insurance is responsible for
recommending a tariff for services payable by the NWT
Medical Care Plan, though it is the Minister who ultimately
Canada Health Act — Annual Report 2011–2012
Chapter 3: Northwest Territories
determines if services will be added, altered or deleted from
insured physician services 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
The Workers’ Safety and Compensation Committee has
several policies that are applied when interpreting the
Workers’ Compensation Act(s). 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.
• approving the fees and charges itemized in the tariff
that may be paid in respect to insured services rendered
by medical practitioners, whether in or outside 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 Insured Services regarding
the appropriateness of the request.
Canada Health Act — Annual Report 2011–2012
3.0 Universality
3.1Eligibility
The Northwest Territories (NWT) uses the Health Care Plan
Registration Guidelines, defined in the Medical Care Act, in
accordance with the Interprovincial Agreement on Eligibility
and Portability, to determine eligibility and fulfill obligations
of section 10 in the Canada Health Act.
Ineligible individuals for NWT health care coverage are
members of the Canadian Forces, the Royal Canadian
Mounted Police (RCMP), 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.
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.
In order to register, residents fill out an application form and
provide applicable documentation (e.g. visa, immigration
papers, proof of residency if requested). Residents may register
prior to eligibility. Registration is directly linked to eligibility
and claims are only paid if the client has registered.
As of March 31, 2012 there were 44,216 individuals registered
with the NWT Health Care Plan.
No formal terms exist for clients to opt out of the NWT Health
Care Plan.
3.2 Other Categories of Individuals
Holders of employment visas, student visas and, in some
cases, visitor visas are covered if they meet the provisions
of the Eligibility and Portability Agreement and Guidelines
for health care plan coverage.
125
Chapter 3: Northwest Territories
4.0Portability
4.1 Minimum Waiting Period
Waiting periods for persons moving to the Northwest
Territories (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, in accordance 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 to leave for work, travel or holidays.
Full time students attending post-secondary school are covered
as well. The full cost of insured services is paid for all services
received in other jurisdictions.
With an NWT health care card, most medical practitioner visits and hospital services are billed directly to the
Department. Reimbursement guidelines exist for patients
having to pay up front for medically required services.
During the reporting period over 19 million dollars were
paid out for hospital in-patient and out-patient services
in other provinces and territories.
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
Through the Medical Care Act, section 4(3), the NWT
Health Care Plan Registration Guidelines provide criteria
that define medical practitioner and hospital fees payable
for costs incurred by NWT residents while they are out of
Canada on a temporary basis.
126
Per section 11(1)(b)(ii) of the Canada Health Act the NWT
provides reimbursement for NWT residents who require
medically necessary services while temporarily outside Canada.
Individuals are required to pay up front and seek reimbursement upon their return to the NWT. 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 barrier free access to
necessary medical services for Northwest Territories (NWT)
residents, in accordance with section 12(1)(a) of the Canada
Health Act. The Medical Travel Program, through an approval
process, guarantees rural residents access to regional or territorial centers for services not available in the individual’s
community, and all NWT residents access to services not
offered in the NWT through contractual agreements with
southern health authorities.
Telehealth services increase accessibility to insured health
services throughout the territory. Every community in the
NWT now has access to Telehealth. The only exception is the
hamlet of Enterprise, which shares services with neighbouring Hay River. All NWT residents, including those in isolated
communities, have access to all Government of the Northwest
Territories (GNWT) facilities via the Medical Travel Program
and Telehealth, including access to specialists, rehabilitation
professionals and other medical practitioners. In 2011–2012
the number of trained Home Support Workers was increased
to enable authorities to increase the hours available to clients
allowing for evening/weekend coverage and/or to increase
staffing levels at peak times. This was critical as the NWT
health and social services system needed to respond to the
new 48-hour rapid discharge of patients from Alberta.
Extra-billing is not permitted in the NWT, in adherence to
section 14 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 2011–2012
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 GNWT,
while the remainder are mostly 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 Northwest Territories.
Canada Health Act — Annual Report 2011–2012
6.0 Recognition Given To
Federal Transfers
Federal Funding from the Canada Health Transfer has been
recognized and reported by the GNWT through press releases
and other documents.
For the current reporting period these documents include:
•
•
•
•
2011–2012 Budget Address;
2011–2012 Main Estimates;
2011–2012 Public Accounts;
2011–2012 Business Plan for the Department of Health
and Social Services;
• 2011–2012 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. 2011–2012 estimates are
based on claim data as of September 21, 2012.
127
Chapter 3: Northwest Territories
Registered Persons
1. Number as of March 31st (#).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
45,927
46,699
47,544
43,639
44,216
Insured Hospital Services Within Own Province or Territory
Public Facilities
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
4. Number of private for-profit facilities
providing insured health services (#).
5. Payments to private for-profit facilities
for insured health services ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
27
27
27
27
27
85,365,096
74,254,097
74,626,037
69,607,096
79,157,702
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
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 ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
1,198
1,174
1,104
1,098
1,095
12,824,618
13,157,987
12,312,420
14,793,910
15,004,206
11,915
12,355
11,588
10,576
11,263
2,742,122
3,574,665
3,473,391
3,517,806
3,959,643
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11. Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
8
11
8
7
12
41,786
24,078
33,175
54,896
38,898
43
39
44
53
38
6,666
13,642
13,774
31,185
19,524
All data are subject to future revisions.
128
Canada Health Act — Annual Report 2011–2012
Chapter 3: Northwest Territories
Insured Physician Services Within Own Province or Territory
2007–2008
14.Number of participating physicians (#).
286
2008–2009
1
276
2009–2010
1
282
2010–2011
290
1
2011–2012
1
285
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
34,266,756
35,751,371
37,467,787
39,063,498
39,478,160
1,791,633
1,929,988
1,872,250
1,699,724
1,633,581
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
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
45,412
46,388
34,264
36,722
37,246
4,118,883
4,219,175
4,096,076
4,943,782
3,841,699
19. Number of services (#).
20.Total payments ($).
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
95
113
118
116
91
9,051
6,230
6,883
9,750
9,245
Insured Surgical-Dental Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
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 2011–2012
129
130
Canada Health Act — Annual Report 2011–2012
Chapter 3: Nunavut
one quarter of the Department’s total operational budget is
spent on costs associated with medical travel and treatment
provided in out-of-territory facilities. Due to the very low
population density in this vast territory and limited health
infrastructure (i.e., diagnostic services), access to a range of
hospital and specialist services often requires that residents
be sent out of the territory. An additional $34,861,000 was
allocated to the Department for capital projects.6
Nunavut
Introduction
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.
The health status of Nunavummiut is significantly below the
national average, and overall life expectancy trails the Canadian
average by 10 years.3 There are no roads or railways connecting Nunavut’s communities, and air travel is the only means of
travelling into, around and out of the territory. As the cost of
airfare, agency nurses, medical technology, infrastructure and
other related expenditures continues to rise, the Government
of Nunavut continues to invest additional resources into public
health; by making investments in health promotion and preventative care now, the high cost of primary health care in the
future can be offset.4
The Government of Nunavut strives to incorporate 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, community health nurses, and pharmacists.
In 2011–2012, the territorial operations and maintenance
budget for the Department of Health and Social Services was
$323,880,000, after supplementary appropriations.5 Over
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
The health care insurance plans of Nunavut, including
physician and hospital services, are administered by the
Department 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 Department retained
regional operations in each region of Nunavut to support
front-line workers and community based delivery of a wide
range of health and social services programs and services.
There were no legislative amendments in 2011–2012.
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
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
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, 2011–2014 Business Plan
4. Government of Nunavut, 2011–2014 Business Plan
5. Government of Nunavut Supplementary Appropriations for the year ended March 31, 2012
6. Government of Nunavut Capital Estimates for the year ended March 31, 2012
Canada Health Act — Annual Report 2011–2012
131
Chapter 3: Nunavut
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 5, 2011.
2.0Comprehensiveness
2.1 Insured Hospital Services
Insured hospital services are provided in Nunavut under the
authority of the Hospital Insurance and Health and Social
Services Administration Act and regulations, sections 2 to 4.
No amendments were made to the Act or regulations in
2011–2012.
In 2011–2012 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). There is also rehabilitative treatment 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 are provided care by on-call staff; and Cambridge
Bay is providing daily clinic hours, and emergency care 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. 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
132
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 2011–2012 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 2011–2012. 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 (Canada) and be licensed to
practice in Nunavut. The Government of Nunavut’s Medical
Registration Committee currently manages this process
for Nunavut physicians. Nunavut recruits and hires its own
family physicians, and accesses specialist services primarily from its main referral centres in Ottawa, Winnipeg, and
Yellowknife. Recruitment of full-time family physicians has
improved significantly and there are 26 family physician
Canada Health Act — Annual Report 2011–2012
Chapter 3: Nunavut
positions funded through the Department, providing over
5,000 days of service annually across the territory.
on a regular basis, but on rare occasions, for medically complicated situations, patients are flown out of the territory.
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 Qiqiktani General Hospital). Visiting specialists, general
practitioners and locums, through arrangements made by
each of the Department’s three regions, also provide insured
physician services. 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 2011–2012, no physicians provided written notice of this election.
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 2011–2012.
All physicians practicing in Nunavut are under contract with
the Department.
Insured physician services refer to all services rendered by
medical practitioners that are medically required. Where
insured services are unavailable in some places in Nunavut,
the patient is referred to another jurisdiction to obtain the
insured service. Nunavut has health service agreements
with medical and treatment centres in Ottawa, Winnipeg,
Churchill, Yellowknife and Edmonton. These are the
out-of-territory sites to which Nunavut mainly refers its
patients to access medical services not available within
the territory.
The addition or deletion of insured physician services
requires government approval. For this, the Director of
Medical Insurance would become involved in negotiations
with a collective group of physicians to discuss the service.
Then the decision of the group would be presented to Cabinet
for approval. No insured physician services were added or
deleted in 2011–2012.
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
Canada Health Act — Annual Report 2011–2012
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services
Services provided under the Workers’ Compensation Act
(NWT, 1988 and as duplicated for Nunavut by section 29
of the Nunavut Act, 1999) or other Acts of Canada, except
the Canada Health Act, are excluded.
Services provided by physicians that are not insured include:
yearly physicals; cosmetic surgery; services that are considered
experimental; prescription drugs; physical examinations done
at the request of a third party; optometric services; dental
services other than specific procedures related to jaw injury or
disease; the services of chiropractors, naturopaths, podiatrists,
osteopaths and acupuncture treatments; and physiotherapy,
speech therapy and psychology services received in a facility
that is not an insured out-patient facility (hospital).
Services not covered in a hospital include: hospital charges
above the standard ward rate for private or semi-private
accommodation; services that are not medically required,
such as cosmetic surgery; services that are considered
experimental; ambulance charges (except inter-hospital
transfers); dental services, other than specific procedures
related to jaw injury or disease; and alcohol and drug
rehabilitation, without prior approval.
In 2011–2012 the Qikiqtani General Hospital charged a
$2,122 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.
133
Chapter 3: Nunavut
3.0Universality
3.1Eligibility
Eligibility for the Nunavut Health Care Plan is briefly defined
under sections 3(1), (2), and (3) of the Medical Care Act. The
Department also adheres to the Interprovincial Agreement
on Eligibility and Portability, as well as internal guidelines.
No amendments were made to the Act or regulations in
2011–2012.
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 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. Applications are accepted for
health coverage, and supporting documentation is required
to confirm residency. 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/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)7, 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, persons 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, 2012, 35,893 individuals were registered with
the Nunavut Health Care Plan, up by 378 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 one exception) are not eligible for coverage.
When unique circumstances occur, assessments are done
on an individual basis. This is consistent with section 15 of
the Northwest Territories’ Guidelines for Health Care Plan
Registration, which was adopted by Nunavut in 1999.
4.0Portability
4.1 Minimum Waiting Period
Consistent with section 3 of the Interprovincial Agreement on
Eligibility and Portability, the waiting period before coverage
begins for individuals moving within Canada is three months,
or the first day of the third month following the establishment
of residency in a new province or territory, or the first day of
the third month when an individual, who has been temporarily
absent from his or her home province, decides to take up permanent residency in Nunavut.
4.2 Coverage During Temporary Absences
in Canada
The Medical Care Act, section 4(2), prescribes the benefits
payable where insured medical services are provided outside
Nunavut, but within Canada. The Hospital Insurance and
Health and Social Services Administration Act, sections 5(d)
and 28(1)(j)(o), provide the authority for the Minister to enter
into agreements with other jurisdictions to provide health
services to Nunavut residents and the terms and conditions
of payment. No legislative or regulatory changes were made
in 2011–2012 with respect to coverage outside Nunavut.
Students studying outside Nunavut must notify the
Department and provide proof of enrolment to ensure
continuing coverage. Requests for extensions must be
7. 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.
134
Canada Health Act — Annual Report 2011–2012
Chapter 3: Nunavut
renewed yearly and are subject to approval by the Director.
Temporary absences for work, vacation or other reasons for
up to one year are approved by the Director upon receipt of
a written request from the insured person. The Director may
approve absences in excess of 12 continuous months upon
receiving a written request from the insured individual.
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 person or directly to
the provider of the insured service.
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.
4.4 Prior Approval Requirement
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. A
special agreement exists between the Northwest Territories
and Nunavut, which, based on a block-funding approach,
enables the Stanton Hospital in Yellowknife to provide
services to Nunavut residents in the hospital and through
visiting specialist services in the Kitikmeot area (western
part of the territory).
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 $2,122 per day and $270 for out-patient care. These rates
increased by $76 and $10 respectively from 2011–2012.
Canada Health Act — Annual Report 2011–2012
Prior approval is required for elective services provided in private
facilities in Canada or in any facility outside the country.
5.0Accessibility
5.1 Access to Insured Health Services
The Medical Care Act, section 14, prohibits extra billing
by physicians unless the medical practitioner has made
an election that is still in effect. Access to insured services
is provided on uniform terms and conditions. To break
down the barrier posed by distance and cost of travel, the
Government of Nunavut provides medical travel assistance.
Interpretation services in the Inuit language are also provided to patients in any health care setting.
The Qikiqtani General Hospital in Iqaluit is the only operating
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 orthopaedics,
gynaecology, paediatrics, general abdominal, emergency trauma
and ENT/otolaryngology. Patients requiring specialized surgeries
are sent to other jurisdictions. Diagnostic services include
radiology, laboratory and electrocardiogram. Rehabilitative
services are limited to Iqaluit. Although nursing and other health
professionals were not at full capacity, all essential acute, public,
dental and mental health services were provided in 2011–2012.
Outside of Iqaluit, out-patient and 24-hour emergency
nursing services are provided by local health centres in
Nunavut’s 24 other communities. Telehealth services are
available in all 25 communities in Nunavut. The long-term
goal is to integrate Telehealth into the primary care delivery
system, enabling residents of Nunavut greater access to
a broader range of service options, and allowing service
providers and communities to use existing resources
more effectively.
135
Chapter 3: Nunavut
Nunavut has agreements in place with a number of out-ofterritory regional health authorities and specific facilities to
provide medical specialists and other visiting health practitioner services. The following specialist services were provided
in Nunavut during 2011–2012 under the visiting specialists
program: ophthalmology; orthopaedics; internal medicine;
otolaryngology; neurology; rheumatology; dermatology;
paediatrics; obstetrics; physiotherapy; occupational therapy;
psychiatry; oral surgery and allergist. Visiting specialist clinics
are held depending on demand and availability of specialists.
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 counselling sessions; family
visitation; and continuing medical education.
For services and equipment unavailable in Nunavut, patients
are referred to other jurisdictions.
5.3 Payments to Hospitals
Funding for the Qiqiktani 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 2011–2012, they included:
• 2011–2012 Budget Address; and
• 2011–2014 Government of Nunavut Business Plan.
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.
136
Canada Health Act — Annual Report 2011–2012
Chapter 3: Nunavut
Registered Persons
2007–2008
2008–2009
2009–2010
2010–2011
31,412
32,207
33,540
35,515
1. Number as of March 31st (#).
2011–2012
8
35,893
Insured Hospital Services Within Own Province or Territory
Public Facilities
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
28
28
28
28
28
not available
not available
not available
not available
not available
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
4. Number of private for-profit facilities
providing insured health services (#).
0
0
0
0
0
5. Payments to private for-profit facilities
for insured health services ($).
0
0
0
0
0
2. Number (#).
3. Payments for insured health services ($).
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
2,255
2,841
2,890
2,924
3,406
19,001,348
26,481,948
30,013,566
28,527,577
38,486,274
15,192
19,579
18,270
18,352
22,725
3,659,654
6,631,568
5,985,808
6,318,885
8,975,802
6. Total number of claims, in-patient (#).
7. Total payments, in-patient ($).
8. Total number of claims, out-patient (#).
9. Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
0
0
0
0
0
11. Total payments, in-patient ($).
0
0
0
0
0
12.Total number of claims, out-patient (#).
0
0
0
0
0
13.Total payments, out-patient ($).
0
0
0
0
0
8. The difference in the number of registered Nunavut residents and those covered under the Nunavut Health Care Plan is due to delays in the reconciliation of data on
residents who have left the territory.
Canada Health Act — Annual Report 2011–2012
137
Chapter 3: Nunavut
Insured Physician Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
156
218
225
225
375
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
not available
not available
not available
not available
not available
2,158,549
1,021,829
300,980
312,786
334,539
14.Number of participating physicians (#).
17. Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).9
Insured Physician Services Provided to Residents in Another Province or Territory
19. Number of services (#).
20.Total payments ($).
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
53,022
65,171
72,065
73,564
75,108
3,845,570
4,768,388
5,585,067
5,901,962
6,393,341
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
15
36
17
53
22
796
2,458
4,848
1,575
963
Insured Surgical-Dental Services Within Own Province or Territory
2007–2008
2008–2009
2009–2010
2010–2011
2011–2012
23.Number of participating dentists (#).
not available
not available
not available
not available
not available
24.Number of services provided (#).
not available
not available
not available
not available
not available
25.Total payments ($).
not available
not available
not available
not available
not available
9. 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.
138
Canada Health Act — Annual Report 2011–2012
Annex A: Canada Health Act and the Extra-Billing and User Charges Information Regulations
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 Infor-mation 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 2011–2012
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.
139
140
Canada Health Act — Annual Report 2011–2012
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 2011–2012
141
Published
consolidation is
evidence
Inconsistencies
in Acts
142
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 2011–2012
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,
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, 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 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 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 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 future improvements in health will require the cooperative partnership of governments, health professionals, voluntary organizations and individual Canadians;
—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 2011–2012
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
143
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.
1984, c. 6, s. 1.
INTERPRETATION
Definitions
DÉFINITIONS
2. Les définitions qui suivent s’appliquent à
la présente loi.
2. In this Act,
“Act of 1977” [Repealed, 1995, c. 17, s. 34]
“cash
contribution”
« contribution
pécuniaire »
« assuré » Habitant d’une province, à l’exception :
“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;
a) des membres des Forces canadiennes;
“extended health
care services”
« services
complémentaires
de santé »
“dentist” means a person lawfully entitled to
practise dentistry in the place in which the
practice is carried on by that person;
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.
“extended health care services” means the following services, as more particularly defined in
the regulations, provided for residents of a
province, namely,
(b) adult residential care service,
« contribution » [Abrogée, 1995, ch. 17, art. 34]
(c) home care service, and
« 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.
(d) ambulatory health care service;
“health care
insurance plan”
« régime
d’assurancesanté »
144
« 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;
(a) nursing home intermediate care service,
“extra-billing”
« surfacturation »
Définitions
b) [Abrogé, 2012, ch. 19, art. 377]
“contribution” [Repealed, 1995, c. 17, s. 34]
“dentist”
« dentiste »
Titre abrégé
1984, ch. 6, art. 1.
“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;
« dentiste » Personne légalement autorisée à
exercer la médecine dentaire au lieu où elle se
livre à cet exercice.
“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;
« frais modérateurs » Frais d’un service de santé
assuré autorisés ou permis par un régime provincial d’assurance-santé mais non payables,
2
« contribution
pécuniaire »
“cash
contribution”
« dentiste »
“dentist”
« frais
modérateurs »
“user charge”
Canada Health Act — Annual Report 2011–2012
Santé — 8 juillet 2012
“health care
practitioner”
« professionnel
de la santé »
“hospital”
« hôpital »
“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” 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.
(a) a hospital or institution primarily for the
mentally disordered, or
« 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 :
(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 »
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.
« loi de 1977 » [Abrogée, 1995, ch. 17, art. 34]
(b) nursing service,
« médecin » Personne légalement autorisée à
exercer la médecine au lieu où elle se livre à cet
exercice.
(c) laboratory, radiological and other diagnostic procedures, together with the necessary interpretations,
« ministre » Le ministre de la Santé.
(d) drugs, biologicals and related preparations when administered in the hospital,
« 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.
(e) use of operating room, case room and
anaesthetic facilities, including necessary
equipment and supplies,
« 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.
(f) medical and surgical equipment and supplies,
(g) use of radiotherapy facilities,
« services complémentaires de santé » Les services définis dans les règlements et offerts aux
habitants d’une province, à savoir :
(h) use of physiotherapy facilities, and
(i) services provided by persons who receive
remuneration therefor from the hospital,
a) les soins intermédiaires en maison de repos;
but does not include services that are excluded
by the regulations;
« médecin »
“medical
practitioner”
« ministre »
“Minister”
« professionnel
de la santé »
“health care
practitioner”
« régime
d’assurancesanté »
“health care
insurance plan”
« services
complémentaires
de santé »
“extended health
care services”
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-
Canada Health Act — Annual Report 2011–2012
« hôpital »
“hospital”
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,
(a) accommodation and meals at the standard or public ward level and preferred accommodation if medically required,
“insured health
services”
« services de
santé assurés »
« habitant »
“resident”
c) les soins à domicile;
d) les soins ambulatoires.
3
145
Canada Health — July 8, 2012
ture of a province that relates to workers' or
workmen’s compensation;
“insured person”
« assuré »
« 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.
“insured person” means, in relation to a
province, a resident of the province other than
(a) a member of the Canadian Forces,
« 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.
(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 »
“Minister”
« ministre »
“physician
services”
« services
médicaux »
“resident”
« habitant »
“surgical-dental
services”
« services de
chirurgie
dentaire »
“user charge”
« frais
modérateurs »
« 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 :
“medical practitioner” means a person lawfully
entitled to practise medicine in the place in
which the practice is carried on by that person;
« services de
santé assurés »
“insured health
services”
« 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;
“Minister” means the Minister of Health;
b) les services infirmiers;
“physician services” means any medically required services rendered by medical practitioners;
c) les actes de laboratoires, de radiologie ou
autres actes de diagnostic, ainsi que les interprétations nécessaires;
“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;
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;
“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;
f) le matériel et les fournitures médicaux et
chirurgicaux;
“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.
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.
« services médicaux » Services médicalement
nécessaires fournis par un médecin.
« surfacturation » Facturation de la prestation à
un assuré par un médecin ou un dentiste d’un
146
« services de
chirurgie
dentaire »
“surgical-dental
services”
4
« services
médicaux »
“physician
services”
« surfacturation »
“extra-billing”
Canada Health Act — Annual Report 2011–2012
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.
CANADIAN HEALTH CARE POLICY
Primary
objective of
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.
PURPOSE
RAISON D’ÊTRE
1984, c. 6, s. 3.
Purpose of this
Act
1984, ch. 6, art. 3.
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.
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.
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;
Règle générale
a) la gestion publique;
(b) comprehensiveness;
b) l’intégralité;
(c) universality;
c) l’universalité;
(d) portability; and
d) la transférabilité;
Canada Health Act — Annual Report 2011–2012
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
Raison d’être de
la présente loi
L.R. (1985), ch. C-6, art. 4; 1995, ch. 17, art. 35.
CASH CONTRIBUTION
Cash
contribution
Objectif premier
5
147
Canada Health — July 8, 2012
(e) accessibility.
e) l’accessibilité.
1984, c. 6, s. 7.
Public
administration
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
(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.
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.
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.
Intégralité
1984, ch. 6, art. 9.
1984, c. 6, s. 9.
Universality
Désignation
d’un mandataire
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.
Comprehensiveness
Gestion
publique
Universalité
1984, ch. 6, art. 10.
148
6
Canada Health Act — Annual Report 2011–2012
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
(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-
Canada Health Act — Annual Report 2011–2012
Transférabilité
(2) La condition de transférabilité n’est pas
enfreinte du fait qu’il faut, aux termes du régime d’assurance-santé d’une province, le
consentement préalable de l’autorité publique
qui le gère pour la prestation de services de
7
Consentement
préalable à la
prestation des
services de santé
assurés
facultatifs
149
Canada Health — July 8, 2012
Definition of
"elective insured
health services"
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.
Accessibility
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
150
Canada Health Act — Annual Report 2011–2012
8
Santé — 8 juillet 2012
to in paragraph (a), conciliation or binding
arbitration by a panel that is equally representative of the provincial organizations and
the province and that has an independent
chairman; and
ganisations provinciales et la province et
ayant un président indépendant;
c) l’impossibilité de modifier la décision du
groupe visé à l’alinéa b), sauf par une loi de
la province.
(c) that a decision of a panel referred to in
paragraph (b) may not be altered except by
an Act of the legislature of the province.
1984, ch. 6, art. 12.
1984, c. 6, s. 12.
CONDITIONS FOR CASH CONTRIBUTION
Conditions
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
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.
Referral to
Governor in
Council
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
151
Canada Health Act — Annual Report 2011–2012
9
Canada Health — July 8, 2012
(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;
a) envoie par courrier recommandé à son
homologue chargé de la santé dans la province un avis sur tout problème éventuel;
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) 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.
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,
c) si la province le lui demande, tient une
réunion dans un délai acceptable afin de discuter du rapport.
(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.
1984, ch. 6, art. 14.
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 :
Amending
orders
Notice of order
152
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) 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.
Impossibilité de
consultation
b) soit, s’il l’estime indiqué, ordonner la retenue de la totalité de la contribution pécuniaire d’un exercice à la province.
(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.
(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
10
Modification des
décrets
Avis
Canada Health Act — Annual Report 2011–2012
Santé — 8 juillet 2012
Commencement
of order
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).
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.
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.
EXTRA-BILLING AND USER CHARGES
SURFACTURATION ET FRAIS
MODÉRATEURS
R.S., 1985, c. C-6, s. 15; 1995, c. 17, s. 38.
Reimposition of
reductions or
withholdings
R.S., 1985, c. C-6, s. 16; 1995, c. 17, s. 39.
When reduction
or withholding
imposed
R.S., 1985, c. C-6, s. 17; 1995, c. 17, s. 39.
Extra-billing
User charges
Limitation
L.R. (1985), ch. C-6, art. 15; 1995, ch. 17, art. 38.
Nouvelle
application des
réductions ou
retenues
L.R. (1985), ch. C-6, art. 16; 1995, ch. 17, art. 39.
Application aux
exercices
ultérieurs
L.R. (1985), ch. C-6, art. 17; 1995, ch. 17, art. 39.
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.
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.
(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
1984, c. 6, s. 18.
Entrée en
vigueur du
décret
Surfacturation
1984, ch. 6, art. 18.
Frais
modérateurs
Réserve
1984, c. 6, s. 19.
Canada Health Act — Annual Report 2011–2012
11
153
Canada Health — July 8, 2012
moins permanente à l’hôpital ou dans une autre
institution.
Deduction for
extra-billing
Deduction for
user charges
Consultation
with province
Separate
accounting in
Public Accounts
Refund to
province
Saving
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.
(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.
(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.
(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.
(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.
(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.
1984, c. 6, s. 20.
154
1984, ch. 6, art. 19.
Déduction en
cas de
surfacturation
Déduction en
cas de frais
modérateurs
Consultation de
la province
Comptabilisation
Remboursement
à la province
Réserve
1984, ch. 6, art. 20.
12
Canada Health Act — Annual Report 2011–2012
Santé — 8 juillet 2012
When deduction
made
21. Any deduction from a cash contribution
under section 20 may be made in the fiscal year
in which the matter that gave rise to the deduction occurred or in the following two fiscal
years.
21. Toute déduction d’une contribution pécuniaire visée à l’article 20 peut être appliquée
pour l’exercice où le fait à son origine a eu lieu
ou pour les deux exercices suivants.
REGULATIONS
RÈGLEMENTS
1984, c. 6, s. 21.
Regulations
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
1984, ch. 6, art. 21.
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 :
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
Agreement of
provinces
Exception
Consultation
with provinces
Annual report by
Minister
d) prévoir la façon dont il doit être fait état
du Transfert en vertu de l’alinéa 13b).
(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.
(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.
(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.
REPORT TO PARLIAMENT
RAPPORT AU PARLEMENT
R.S., 1985, c. C-6, s. 22; 1995, c. 17, s. 40; 2012, c. 19, s.
410(E).
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
Canada Health Act — Annual Report 2011–2012
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;
(d) prescribing the manner in which recognition to the Canada Health Transfer is required to be given under paragraph 13(b).
Application aux
exercices
ultérieurs
Consentement
des provinces
Exception
Consultation des
provinces
L.R. (1985), ch. C-6, art. 22; 1995, ch. 17, art. 40; 2012, ch.
19, art. 410(A).
23. Au plus tard pour le 31 décembre de
chaque année, le ministre établit dans les
meilleurs délais un rapport sur l’application de
13
Rapport annuel
du ministre
155
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.
1984, c. 6, s. 23.
156
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.
14
Canada Health Act — Annual Report 2011–2012
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 2011–2012
157
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
158
(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 2011–2012
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 2011–2012
1
159
SOR/86-259 — November 30, 2010
4. For the purposes of paragraph 13(a) of the Act, the
Minister may require the government of a province to
provide the Minister with information of the following
types with respect to user charges in the province in a
fiscal year:
4. Pour l’application de l’alinéa 13a) de la Loi, le ministre peut exiger que le gouvernement d’une province
lui fournisse les renseignements suivants sur les montants des frais modérateurs imposés dans la province au
cours d’un exercice :
(a) an estimate of the aggregate amount that, at the
time the estimate is made, is expected to be charged in
respect of user charges to which section 19 of the Act
applies, including an explanation regarding the
method of determination of the estimate; and
a) une estimation du montant total, à la date de l’estimation, des frais modérateurs visés à l’article 19 de la
Loi, accompagnée d’une explication de la façon dont
cette estimation a été obtenue;
b) un état financier indiquant le montant total des
frais modérateurs visés à l’article 19 de la Loi effectivement imposés dans la province, accompagné d’une
explication de la façon dont le bilan a été établi.
(b) a financial statement showing the aggregate
amount actually charged in respect of user charges to
which section 19 of the Act applies, including an explanation regarding the method of determination of
the aggregate amount.
TIMES AND MANNER OF FILING INFORMATION
COMMUNICATION DE RENSEIGNEMENTS
5. (1) The government of a province shall provide
the Minister with such information, of the types prescribed by sections 3 and 4, as the Minister may reasonably require, at the following times:
5. (1) Le gouvernement d’une province doit communiquer au ministre les renseignements visés aux articles
3 et 4, dont le ministre peut normalement avoir besoin,
selon l’échéancier suivant :
(a) in respect of the estimates referred to in paragraphs 3(a) and 4(a), before April 1 of the fiscal year
to which they relate; and
a) pour les estimations visées aux alinéas 3a) et 4a),
avant le 1er avril de l’exercice visé par ces estimations;
b) pour les états financiers visés aux alinéas 3b) et
4b), avant le seizième jour du vingt et unième mois
qui suit la fin de l’exercice visé par ces états.
(b) in respect of the financial statements referred to in
paragraphs 3(b) and 4(b), before the sixteenth day of
the twenty-first month following the end of the fiscal
year to which they relate.
(2) The government of a province may, at its discretion, provide the Minister with adjustments to the estimates referred to in paragraphs 3(a) and 4(a) before
February 16 of the fiscal year to which they relate.
(2) Le gouvernement d’une province peut, à sa discrétion, fournir au ministre des ajustements aux estimations prévues aux alinéas 3a) et 4a), avant le 16 février
de l’année financière visée par ces estimations.
(3) The information referred to in subsections (1) and
(2) shall be transmitted to the Minister by the most practical means of communication.
(3) Les renseignements visés aux paragraphes (1) et
(2) doivent être expédiés au ministre par le moyen de
communication le plus pratique.
2
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Annex B: Policy Interpretation Letters
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 2011–2012
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/
territorial health insu­rance plan pays the physician fee for
a medically necessary service delivered at a private clinic,
it must also pay the facility fee or face a deduction from
federal transfer payments.
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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 and out-patient
hospital services associated with the provision of acute, rehabilitative and chronic care. As regards physician services, the range of
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Annex B: Policy Interpretation Letters
insured services generally encompasses medically required services rendered by licensed medical practitioners as well as surgicaldental procedures that require a hospital for proper performance. Services rendered by other health care practitioners, except
those required to provide necessary hospital services, are not subject to the Act’s criteria.
Within these broad parameters, provinces, along with medical professionals, have the prerogative and responsibility for interpreting what physician services are medically necessary. As well, provinces determine which hospitals and hospital services are
required to provide acute, rehabilitative or chronic care.
Universality
The intent of the Canada Health Act is to ensure that all bonafide residents of all provinces be entitled to coverage and to the benefits
under one of the twelve provincial/territorial health care insurance plans. However, eligible residents do have the option not to
participate under a provincial plan should they elect to do so.
The Agreement on Eligibility and Portability provides some helpful guidelines with respect to the deter­mination of residency
status and arrangements for obtaining and maintaining coverage. Its provisions are compatible with the Canada Health Act.
I want to say a few words about premiums. Unquestionably, provinces have the right to levy taxes and the Canada Health Act
does not infringe upon that right. A premium scheme per se is not precluded by the Act, provided that the provincial health care
insurance plan is operated and administered in a manner that does not deny coverage or preclude access to necessary hospital
and physician services to bonafide residents of a province. Administrative arrangements should be such that residents are not
precluded from or do not forego coverage by reason of an inability to pay premiums.
I am acutely aware of problems faced by some provinces in regard to tourists and visitors who may require health services while
travelling in Canada. I will be undertaking a review of the current practices and procedures with my Cabinet colleagues, the
Minister of External Affairs, and the Minister of Employment and Immigration, to ensure all reasonable means are taken to
inform prospective visitors to Canada of the need to protect themselves with adequate health insurance coverage before entering
the country.
In summary, I believe all of us as Ministers of Health are committed to the objective of ensuring that all duly qualified residents
of a province obtain and retain entitlement to insured health services on uniform terms and conditions.
Portability
The intent of the portability provisions of the Canada Health Act is to provide insured persons continuing protection under their
provincial health care insurance plan when they are temporarily absent from their province of residence or when moving from
province to province. While temporarily in another province of Canada, bonafide residents should not be subject to out-of-pocket
costs or charges for necessary hospital and physician services. Providers should be assured of reasonable levels of payment in respect
of the cost of those services.
Insofar as insured services received while outside of Canada are concerned, the intent is to assure reasonable indemni­fication
in respect of the cost of necessary emergency hospital or physician services or for referred services not available in a province or
in neighbouring provinces. Generally speaking, payment formulae tied to what would have been paid for similar services in a
province would be acceptable for purposes of the Canada Health Act.
In my discussions with provincial/territorial Ministers, I detected a desire to achieve these portability objectives and to minimize
the difficulties that Canadians may encounter when moving or travelling about in Canada. In order that Canadians may maintain
their health insurance coverage and obtain benefits or services without undue impediment, I believe that all provincial/territorial
Health Ministers are interested in seeing these services provided more efficiently and economically.
Significant progress has been made over the past few years by way of reciprocal arrangements which contribute to the achievement of the in-Canada portability objectives of the Canada Health Act. These arrangements do not interfere with the rights and
prerogatives of provinces to determine and provide the coverage for services rendered in another province. Likewise, they do
not deter provinces from exercising reasonable controls through prior approval mechanisms for elective procedures. I recognize
that work remains to be done respecting interprovincial payment arrangements to achieve this objective, especially as it pertains
to physician services.
Canada Health Act — Annual Report 2011–2012
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Annex B: Policy Interpretation Letters
I appreciate that all difficulties cannot be resolved overnight and that provincial plans will require sufficient time to meet the
objective of ensuring no direct charges to patients for necessary hospital and physician services provided in other provinces.
For necessary services provided out-of-Canada, I am confident that we can establish acceptable standards of indemnifi­cation
for essential physician and hospital services. The legislation does not define a particular formula and I would be pleased to have
your views.
In order that our efforts can progress in a coordinated manner, I would propose that the Federal-Provincial Advisory Committee
on Institutional and Medical Services be charged with examining various options and recommending arrangements to achieve the
objectives within one year.
Reasonable Accessibility
The Act is fairly clear with respect to certain aspects of accessibility. The Act seeks to discourage all point-of-service charges
for insured services provided to insured persons and to prevent adverse discrimination against any population group with
respect to charges for, or necessary use of, insured services. At the same time, the Act accents a partnership between the providers of insured services and provincial plans, requiring that provincial plans have in place reasonable systems of payment or
compensation for their medical practitioners in order to ensure reasonable access to users. I want to emphasize my intention
to respect provincial prerogatives regarding the organization, licensing, supply, distribution of health manpower, as well as
the resource allocation and priorities for health services. I want to assure you that the reasonable access provision will not
be used to intervene or interfere directly in matters such as the physical and geographic availability of services or provincial
governance of the institutions and professions that provide insured services. Inevitably, major issues or concerns regarding
access to health care services will come to my attention. I want to assure you that my Ministry will work through and with
provincial/territorial Ministers in addressing such matters.
My aim in communicating my intentions with respect to the criteria in the Canada Health Act is to allow us to work together in
developing our national health insurance scheme. Through continuing dialogue, open and willing exchange of information and
mutually understood rules of the road, I believe that we can implement the Canada Health Act without acrimony and conflict.
It is my preference that provincial/territorial Ministers themselves be given an oppor­tunity to interpret and apply the criteria of
the Canada Health Act to their respective health care insurance plans. At the same time, I believe that all provincial/territorial
Health Ministers understand and respect my accountability to the Parliament of Canada, including an annual report on the
operation of provincial health care insurance plans with regard to these fundamental criteria.
Conditions
This leads me to the conditions related to the recognition of federal contributions and to the provision of information, both of
which may be specified in regulations. In these matters, I will be guided by the following principles:
1. to make as few regulations as possible and only if absolutely necessary;
2. to rely on the goodwill of Ministers to afford appropriate recognition of Canada’s role and contribution and to provide
necessary information voluntarily for purposes of administering the Act and reporting to Parliament;
3. to employ consultation processes and mutually beneficial information exchanges as the preferred ways and means of
implementing and administering the Canada Health Act;
4. to use existing means of exchanging information of mutual benefit to all our governments.
Regarding recognition by provincial/territorial governments of federal health contributions, I am satisfied that we can easily agree
on appropriate recognition, in the normal course of events. The best form of recognition in my view is the demonstration to the
public that as Ministers of Health we are working together in the interests of the taxpayer and patient.
In regard to information, I remain committed to maintaining and improving national data systems on a collaborative and
co-operative basis. These systems serve many purposes and provide governments, as well as other agencies, organizations,
and the general public, with essential data about our health care system and the health status of our population. I foresee a
continuing, co-operative partnership committed to maintaining and improving health information systems in such areas as
morbidity, mortality, health status, health services operations, utilization, health care costs and financing.
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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 communi-cation 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 2011–2012
165
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 pro­v ision 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 pro­v ides
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.
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Annex B: Policy Interpretation Letters
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.
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.
Canada Health Act — Annual Report 2011–2012
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Annex B: Policy Interpretation Letters
In closing, I would like to quote Mr. Justice Emmett M. Hall. In 1980, he reminded us:
“ we, as a society, are aware that the trauma of illness, the pain of surgery, the slow decline to death, are burdens enough
for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of
vulnerability.”
I trust that, mindful of these words, we will continue to work together to ensure the survival, and renewal, of what is perhaps
our finest social project.
As the issues addressed in this letter are of great concern to Canadians, I intend to make this letter publicly available once
all provincial Health Ministers have received it.
Yours sincerely,
Diane Marleau
Minister of Health
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Annex C: Dispute avoidance and resolution process under the canada health act
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 pro-vinces 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.
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 process includes the dispute avoidance activities of
government-to-government information exchange; discussions and clarification of issues, as they arise; active
participation of governments in ad hoc federal/provincial/
territorial committees on Canada Health Act issues; and
Canada Health Act advance assessments, upon request.
In September 2004, the agreement reached between the
provinces and territories in 2002 was formalized by First
Ministers, thereby reaffirming their commitment to use the
Canada Health Act dispute avoidance and resolution process
to deal with Canada Health Act interpretation issues.
Where dispute avoidance activities prove unsuccessful,
dispute resolution activities may be initiated, beginning with
government-to-government fact-finding and negotiations. If
Canada Health Act — Annual Report 2011–2012
The federal Minister of Health has the final authority to
interpret and enforce the Canada Health Act. In deciding
whether to invoke the non-compliance provisions of the Act,
the Minister will take the panel’s report into conside­ration.
On the following pages you will find the full text of Minister
McLellan’s letter to the Honourable Gary Mar, as well as a
fact sheet on the Canada Health Act Dispute Avoidance and
Resolution process.
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Annex C: Dispute avoidance and resolution process under the canada health act
Minister of Health
Ministre de la Santé
Ottawa, Canada K1A 0K9
April 2, 2002
The Honourable Gary Mar, M.L.A.
Minister of Health and Wellness
Province of Alberta
Room 323, Legislature Building
Edmonton, Alberta
T5K 2B6
Dear Mr. Mar:
I am writing in fulfilment of my commitment to move forward on dispute avoidance and resolution as it applies to the interpretation
of the principles of the Canada Health Act.
I understand the importance provincial and territorial governments attach to having a third party provide advice and recommendations when differences occur regarding the interpretation of the Canada Health Act. This feature has been incorporated
in the approach to the Canada Health Act Dispute Avoidance and Resolution process set out below. I believe this approach will
enable us to avoid and resolve issues related to the interpretation of the principles of the Canada Health Act in a fair, transparent
and timely manner.
Dispute Avoidance
The best way to resolve a dispute is to prevent it from occurring in the first place. The federal government has rarely resorted to
penalties and only when all other efforts to resolve the issue have proven unsuccessful. Dispute avoidance has worked for us in the
past and it can serve our shared interests in the future. Therefore, it is important that governments continue to participate actively
in ad hoc federal/provincial/territorial committees on Canada Health Act issues and undertake government-to-government
information exchange, discussions and clarification on issues as they arise.
Moreover, Health Canada commits to provide advance assessments to any province or territory upon request.
Dispute Resolution
Where the dispute avoidance activities between the federal government and a provincial or territorial government prove
unsuccessful, either Minister of Health involved may initiate dispute resolution by writing to his or her counterpart. Such a letter
would describe the issue in dispute. If initiated, dispute resolution will precede any action taken under the non-compliance
provisions of the Act.
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Annex C: Dispute avoidance and resolution process under the canada health act
As a first step, governments involved in the dispute will, within 60 days of the date of the letter initiating the process, jointly:
•
•
•
•
collect and share all relevant facts;
prepare a fact-finding report;
negotiate to resolve the issue in dispute; and
prepare a report on how the issue was resolved.
If, however, there is no agreement on the facts, or if negotiations fail to resolve the issue, any Minister of Health involved in the
dispute may initiate the process to refer the issue to a third party panel by writing to his or her counterpart. Within 30 days of
the date of that letter, a panel will be struck. The panel will be composed of one provincial/territorial appointee and one federal
appointee who, together, will select a chairperson. The panel will assess the issue in dispute in accordance with the provisions
of the Canada Health Act, will undertake fact-finding and provide advice and recommendations. It will then report to the
governments involved on the issue within 60 days of appointment.
The Minister of Health for Canada has the final authority to interpret and enforce the Canada Health Act. In deciding whether to
invoke the non-compliance provisions of the Act, the Minister of Health for Canada will take the panel’s report into consideration.
Public Reporting
Governments will report publicly on Canada Health Act dispute avoidance and resolution activities, including any panel report.
I believe that the Government of Canada has followed through on its September 2000 Health Agreement commitments by providing
funding of $21.1 billion in the fiscal framework and by working collaboratively in other areas identified in the agreement. I expect
that provincial and territorial premiers and Health Ministers will honour their commitment to the health system accountability
framework agreed to by First Ministers in September 2000. The work of officials on performance indicators has been collaborative
and effective to date. Canadians will expect us to report on the full range of indicators by the agreed deadline of September 2002.
While I am aware that some jurisdictions may not be able to fully report on all indicators in this timeframe, public accountability
is an essential component of our effort to renew Canada’s health care system. As such, it is very important that all jurisdictions
work to report on the full range of indicators in subsequent reports.
In addition, I hope that all provincial and territorial governments will participate in and complete the joint review process
agreed to by all Premiers who signed the Social Union Framework Agreement.
The Canada Health Act Dispute Avoidance and Resolution process outlined in this letter is simple and straightforward. Should
adjustments be necessary in the future, I commit to review the process with you and other Provincial/Territorial Ministers of
Health. By using this approach, we will demonstrate to Canadians that we are committed to strengthening and preserving medicare
by preventing and resolving Canada Health Act disputes in a fair and timely manner.
Yours sincerely,
A. Anne McLellan
Canada Health Act — Annual Report 2011–2012
171
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/terri­torial
committees on Canada Health Act issues; and
• undertake government-to-government information
exchange, discussions and clarification on issues as
they arise.
Health Canada commits to provide advance assessments to
any province or territory upon request.
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.
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.
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.
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.
As a first step, governments involved in the dispute will, within
60 days of the date of the letter initiating the process, jointly:
•
•
•
•
172
collect and share all relevant facts;
prepare a fact-finding report;
negotiate to resolve the issue in dispute; and
prepare a report on how the issue was resolved.
Canada Health Act — Annual Report 2011–2012
Contact Information for Provincial and Territorial Departments of Health
Newfoundland and Labrador
Manitoba
Department of Health and Community Services
Confederation Building
P.O. Box 8700
St. John’s, NL A1B 4J6
(709) 729-5021
www.gov.nl.ca/health
Manitoba Health
300 Carlton Street
Winnipeg, MB R3B 3M9
1-800-392-1207
www.manitoba.ca/health
Prince Edward Island
Saskatchewan Health
3475 Albert Street
Regina, SK S4S 6X6
1-800-667-7766
www.health.gov.sk.ca
Department of Health and Wellness
P.O. Box 2000
Charlottetown, PE C1A 7N8
(902) 368-6414
www.gov.pe.ca/health
Nova Scotia
Department of Health and Wellness
P.O. Box 488
Halifax, NS B3J 2R8
(902) 424-5818
1-800-387-6665 (toll-free in Nova Scotia)
1-800-670-8888 (TTY/TDD)
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
Alberta
Alberta Health
P.O. Box 1360, Station Main
Edmonton, AB T5J 2N3
(780) 427-7164
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
Box 2703
Financial Plaza
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 and Social Services
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
Public Administration
Comprehensiveness
Universality
Portability
ANNUAL REPORT 2011–2012
ANNUAL REPORT
2011–2012
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