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CANADA HEALTH ACT
CANADA HEALTH ACT
ANNUAL REPORT 2010–2011
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Health Canada is the federal department responsible for helping the people of Canada maintain
and improve their health. Health Canada is committed to improving the lives of all of Canada’s
people and to making this country’s population among the healthiest in the world as measured
by longevity, lifestyle and effective use of the public health care system.
Published by authority of the Minister of Health.
Canada Health Act — Annual Report 2010–2011
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 2010-2011
This publication can be made available on request on diskette, large print, audio-cassette and braille.
For further information or to obtain additional copies, please contact:
Health Canada
Address Locator 0900C2
Ottawa, Ontario K1A 0K9
Telephone: (613) 957-2991
Toll free: 1-866-225-0709
Fax: (613) 941-5366
© Majesty the Queen in Right of Canada, represented by the Minister of Health of Canada, 2011
All rights reserved. No part of this information (publication or product) may be reproduced or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, or stored in a retrieval system,
without prior written permission of the Minister of Public Works and Government Services Canada, Ottawa, Ontario
K1A 0S5 or [email protected]
HC Pub: 110152
Cat.: H1-4/2011E
ISSN: 0842-3202
CKNOWLEDGEMENTS
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 Department of Health and Social Services
Ontario Ministry of Health and Long-Term Care
Manitoba Health
Saskatchewan Health
Alberta Health and Wellness
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 2010–2011
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Canada Health Act — Annual Report 2010–2011
Table of Contents
Acknowledgements_________________________________________________________________________________________ i
Introduction_______________________________________________________________________________________________ 1
Chapter 1 — Canada Health Act Overview_____________________________________________________________________ 3
Chapter 2 — Administration and Compliance__________________________________________________________________ 9
Chapter 3 — Provincial and Territorial Health Care Insurance Plans in 2010–2011_______________________________ 15
Newfoundland and Labrador___________________________________________________________________ 17
Prince Edward Island__________________________________________________________________________ 27
Nova Scotia___________________________________________________________________________________ 35
New Brunswick________________________________________________________________________________ 45
Quebec_______________________________________________________________________________________ 55
Ontario_______________________________________________________________________________________ 61
Manitoba_____________________________________________________________________________________ 73
Saskatchewan_________________________________________________________________________________ 85
Alberta_______________________________________________________________________________________ 95
British Columbia______________________________________________________________________________ 103
Yukon_______________________________________________________________________________________ 117
Northwest Territories_________________________________________________________________________ 127
Nunavut_____________________________________________________________________________________ 135
Annex A — Canada Health Act and Extra-Billing and User Charges Information Regulations___________________ 143
Annex B — Policy Interpretation Letters___________________________________________________________________ 165
Annex C — Dispute Avoidance and Resolution Process under the Canada Health Act___________________________ 175
Provincial and Territorial Departments of Health Contact Information___________________________ inside back cover
Canada Health Act — Annual Report 2010–2011
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Canada Health Act — Annual Report 2010–2011
Introduction
Introduction
Canada has a predominantly publicly financed and
administered health care system. The Canadian health
insurance system is achieved through 13 interlocking
provincial and territorial health insurance plans, and is
designed to ensure that all eligible residents of Canadian
provinces and territories have reasonable access to
medically necessary hospital and physician services
on a prepaid basis, without charges related to the pro­
vision 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 the 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. 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 administration, comprehensiveness, universality,
portability and accessibility. These principles are symbols
of the underlying Canadian values of equity and solidarity.
In 2010–2011, the most prominent concerns with
respect to compliance under the Canada Health Act
remained patient charges and queue jumping for
medically necessary health services at private clinics.
Health Canada has made these concerns known to
the provinces that allow these charges.
Canada Health Act — Annual Report 2010–2011
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CANADA HEALTH ACT  ANNUAL REPORT 20102011
Chapter 1: Canada Health Act Overview
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.”
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.
Key Definitions Under the Canada Health Act
Insured persons are eligible residents of a province or
territory. A resident of a province is defined in the Act
as “a person lawfully entitled to be or to remain
Canada Health Act — Annual Report 2010–2011
Persons excluded under the Act include serving
members of the Canadian Forces or Royal Canadian
Mounted Police 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.
Requirements of the
Canada Health Act
The Canada Health Act contains nine requirements
that the provinces and territories must fulfill in order
to qualify for the full amount of their cash entitlement
under the CHT. They are:
• five program criteria that apply only to insured
health services;
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Chapter 1: Canada Health Act Overview
• t wo conditions that apply to insured health services
and extended health care services; and
not to exceed three months, before they are entitled to
receive insured health services.
• extra-billing and user charges provisions that
apply only to insured health services.
4. Portability (section 11)
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.
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,
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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 also be
required before coverage is extended for elective (nonemergency) services to a resident while temporarily
absent from his/her province or territory.
5. Accessibility (section 12)
The intent of the accessibility criterion is to ensure
that insured persons in a province or territory have
reasonable access to insured hospital, medical and
surgical-dental services on uniform terms and conditions, unprecluded or unimpeded, either directly or
indirectly, by charges (user charges or extra-billing)
or other means (e.g., discrimination on the basis of
age, health status or financial circumstances).
Canada Health Act — Annual Report 2010–2011
Chapter 1: Canada Health Act Overview
In addition, the health care insurance plans of the
province or territory must provide:
• reasonable compensation to physicians and
dentists for all the insured health services they
provide; and
• payment to hospitals to cover the cost of insured
health services.
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 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.
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.
2. Recognition (section 13(b))
The provincial and territorial governments shall
recognize the federal financial contributions toward
both insured and extended health care services.
Extra-billing and User Charges
The provisions of the Canada Health Act pertaining
to extra-billing and user charges for insured health
services in a province or territory are outlined in
sections 18 to 21. If it can be confirmed that either
extra-billing or user charges exist in a province or
territory, a mandatory deduction from the federal
cash transfer to that province or territory is required
under the Act. The amount of such a deduction for
a fiscal year is determined by the federal Minister
of Health based on information provided by the
province or territory in accordance with the Extrabilling and User Charges Information Regulations
(described below).
Canada Health Act — Annual Report 2010–2011
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
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. In plain terms, this means
that when it has been determined that a province or
territory has allowed $500,000 in extra-billing by physicians, the federal cash contribution to that province or
territory will be reduced by that same amount.
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 exclusion for insured services:
• services that fall outside the definition of insured
health services; and
• c ertain services and groups of persons are excluded
from the definitions of insured services and
insured persons.
These exclusions are discussed below.
6
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 Police 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.
Canada Health Act — Annual Report 2010–2011
Chapter 1: Canada Health Act Overview
There is a Frequently Asked Questions link on Health
Canada’s web-site to address common concerns that
Canadians might have about Canada’s publicly-insured
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, thenfederal 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.”
Policy on Private Clinics. The Minister’s letter provided
the federal interpretation of the Canada Health Act as
it relates to the issue of facility fees charged directly to
patients receiving medically necessary services at private
clinics. The letter stated that the definition of “hospital”
contained in the Act includes any public facility that provides acute, rehabilitative or chronic care. Thus, when
a provincial/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/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.
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
Canada Health Act — Annual Report 2010–2011
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Canada Health Act — Annual Report 2010–2011
Chapter 2: Administration and Compliance
• conducting issue analysis and policy research
to provide policy advice;
ChaptER 2
Administration
and Compliance
Administration
In administering the Canada Health Act, the federal
Minister of Health is assisted by Health Canada staff
at headquarters and in the regions, and by the
Department of Justice.
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 fulfill the following
ongoing functions:
• monitoring and analysing provincial and territorial health insurance plans for compliance with
the criteria, conditions and extra-billing and user
charges provisions of the Act;
• disseminating information on the Act and on publicly
funded health care insurance programs in Canada;
• responding to inquiries about the Act and health
insurance issues received by telephone, mail and the
Internet, from the public, members of Parliament,
government departments, stakeholder organizations
and the media;
• developing and maintaining formal and informal
partnerships with health officials in provincial and
territorial governments for information sharing;
• developing and producing the Canada Health
Act Annual Report on the administration and
operation of the Act;
Canada Health Act — Annual Report 2010–2011
• collaborating with provincial and territorial
health department representatives through the
Interprovincial Health Insurance Agreements
Coordinating Committee (see below);
• working in partnership with the provinces and territories to investigate and resolve compliance issues
and pursue activities that encourage compliance
with the Act; and
• informing the Minister of possible non-compliance
and recommending appropriate action to resolve
the issue.
Interprovincial Health Insurance Agreements
Coordinating Committee (IHIACC)
The Canada Health Act Division chairs the Interprovincial
Health Insurance Agreements Coordinating Committee
and provides a secretariat for the Committee. The
Committee was formed in 1991 to address issues affecting the interprovincial billing of hospital and medical
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 Canada Health 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 hospital or physician
services in another province or territory. The province
or territory providing the service will then directly bill
the patient’s home province. All provinces and territories
participate in reciprocal hospital agreements and all,
with the exception of Quebec, participate in reciprocal
medical agreements. The intent of these agreements
is to ensure that Canadian residents do not face pointof-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
9
Chapter 2: Administration and Compliance
disputes and issues related to administering and interpreting the Canada Health Act have 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 miscommunication, and are
resolved quickly with provincial/territorial assistance,
such as eligibility for health insurance coverage and portability of health services within and outside Canada.
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 2011
CHT payments to British Columbia, in respect of extrabilling and patients charges at surgical clinics in the
amount of $75,136, and Newfoundland and Labrador,
in respect of extra-billing in the amount of $3,577,
levied during fiscal year 2008–2009.
During 2010–2011, two potential compliance issues
arose. First, media reports indicated that a private
primary care clinic in Ottawa was planning to charge
10
patients an annual fee to join. Health Canada had
concerns that the payment of the fee might be a condition
for receiving insured health services. Health Canada
officials contacted officials at the Ontario Ministry of
Health and Long-Term Care (MOHLTC) and requested
that they investigate.
In the second instance, further to a media report, Health
Canada raised concerns with the Ontario Ministry of
Health and Long-Term Care about a Toronto hospital
accepting payments for insured diagnostic services
under the guise of a third-party payor arrangement.
In relation to both matters, the MOHLTC advised that they
have taken decisive, corrective action pursuant to the
requirements of the Ontario Commitment to the Future of
Medicare Act. In order to satisfy the requirements of the
Canada Health Act, Health Canada informed the MOHLTC
that these measures must include reimbursement of
extra-billing and user charges to insured Ontario residents, if such contraventions have occurred.
History of Deductions and
Refunds Under the Canada
Health Act
The Canada Health Act, which came into force
April 1, 1984, reaffirmed the national commitment
to the original principles of the Canadian health care
system, as embodied in the previous legislation, the
Medical Care Act and the Hospital Insurance and
Diagnostic Services Act. By putting into place mandatory dollar-for-dollar penalties for extra-billing and
user charges, the federal government took steps to
eliminate the proliferation of direct charges for hospital and physician services, judged to be restricting the
access of many Canadians to health care services due
to financial considerations.
During the period 1984 to 1987, subsection 20(5) of the
Act provided for deductions in respect of these charges
to be refunded to the province if the charges were
eliminated before April 1, 1987. By March 31, 1987,
it was determined that all provinces, which had extrabilling 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).
Canada Health Act — Annual Report 2010–2011
Chapter 2: Administration and Compliance
Following the Canada Health 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/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 extrabilling 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 were
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, 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 $284,430 was deducted from Newfoundland
Canada Health Act — Annual Report 2010–2011
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
for 2002–2003 and one-time positive adjustment in the
amount of $8,121 was made to Nova Scotia’s March
2006 CHT 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.
11
Chapter 2: Administration and Compliance
Since 2005, the following deductions (and the fiscal
year to which they pertained) have been taken to British
Columbia’s CHT payments1 on the basis of charges
reported by the province for extra-billing and patient
charges: $72,464 in 2005 (2002–2003); $29,019 in 2006
(2003–2004); $114,850 in 2007 (2004–2005); $42,113
in 2008 (2005–2006); $66,195 in 2009 (2006–2007);
and $73,925 in 2010 (2007–2008).
A deduction of $1,100 was taken from the March 2005
CHT payment to Newfoundland and Labrador as a result
of patient charges for a magnetic resonance imaging
scan in a hospital which occurred during 2002–2003.
The March 2007 CHT payment to Nova Scotia was
reduced by $9,460 in respect of extra-billing during
fiscal year 2004–2005.
Since the passage of the Canada Health Act, from
April 1984 to March 2011, deductions totalling
$9,238,332 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.
12
Canada Health Act — Annual Report 2010–2011
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
NL
0
46,000
96,000
132,000
53,000
(42,570)
0
0
0
PEI
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
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
269,000
588,000
586,000
612,000
0
0
300,201
0
SK
0
0
0
0
0
0
0
0
0
AB
0
2,319,000
1,266,000
0
0
0
0
0
0
BC
1,982,000
43,000
0
0
0
0
0
0
4,610
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
1,982,000
2,709,000
2,022,000
775,000
703,950
18,540
57,804
335,301
15,662
2003–2004
2004–2005
2005–2006
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
Total
NL
0
1,100
0
0
0
0
0
3,577
289,107
PEI
0
0
0
0
0
0
0
0
0
NS
7,119
5,463
(8,121)
9,460
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
126,775
72,464
29,019
114,850
42,113
66,195
73,925
75,136
2,630,087
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
133,894
79,027
20,898
124,310
42,113
66,195
73,925
78,713
9,238,332
Total
Province/
Territory
Total
Note: Deductions taken in a given year are made to 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 2010–2011
13
14
Canada Health Act — Annual Report 2010–2011
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2010–2011
CHAPTER 3
Provincial and
Territorial Health
Care Insurance
Plans in 2010–2011
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 2010-2011.
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 Canada Health Act, while statistics help
to identify current and future trends in the Canadian
health care system.
Canada Health Act — Annual Report 2010–2011
To help provinces and territories prepare their submissions to the annual report, Health Canada provided them
with the document Canada Health Act Annual Report
2010-2011: A Guide 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
2010-2011 was launched late spring 2011 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
In 2003–2004, the section of the annual report containing
the statistical information submitted from the provinces
and territories was simplified and streamlined following
feedback received from provincial and territorial officials,
and based on a review of data quality and availability.
The format was further streamlined for the 2006–2007
report. In the 2009–2010 report, the tables were again
streamlined to focus on total numbers of physicians and
facilities. This format was retained in 2010–2011. The
supplemental statistical information can be found at the
end of each provincial or territorial narrative, except
for Quebec.
The purpose of the statistical tables is to place the
administration and operation of the Canada Health
Act in context and to provide a national perspective
on trends in the delivery and funding of insured health
services in Canada that are within the scope of the
federal Act.
15
Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2010–2011
The statistical tables contain resource and cost data
for insured hospital, physician and surgical-dental by
province and territory for five consecutive years ending
on March 31, 2011. 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.
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.
16
Insured Hospital Services Provided to Residents
in Another Province or Territory: This sub-section
presents out-of-province or out-of-territory insured
hospital services that are paid for by a person’s
home jurisdiction when they travel to other parts
of Canada.
Insured Hospital Services Provided Outside Canada:
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.
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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Newfoundland and Labrador
program for adolescent females, and to improve access
to cancer care.
1.0 Public Administration
1.1Health Care Insurance Plan and
Public Authority
Newfoundland
and Labrador
Introduction
The majority of publicly funded health services in
Newfoundland and Labrador are delivered through
four regional health authorities. 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 approximately 520,000 residents (based on
2006 census).
There were significant investments in health and well­
being in Budget 2010–2011. Investments of $2.7 billion
were budgeted to improve health care throughout the
province. Investments included $1.2 million to enhance
surgical services at Western Memorial Hospital in Corner
Brook, $1.1 million to decrease wait time for surgery by
increasing the number of operating rooms in the Eastern
Health region, and $797,700 for an expansion of the
coverage for the current insulin pump therapy program,
to include adults from the ages of 18 to 25 years old.
An investment of approximately $7.2 million continued
to ensure that those individuals who live with mental illness or addiction issues have treatment options
available to them. An investment of $1.1 million will
establish two new satellite dialysis units, one for Port
aux Basques and the other for Labrador West. These
units will help reduce the travel and improve the quality of life of patients who will be able to receive dialysis
closer to home. As well, Newfoundland and Labrador
made significant investments, including key investments
to improve access to rural health care services, initiatives that support the health and wellness of children
and youth, which includes $0.8 million to continue to
fund the Human Papillomanvirus (HPV) immunization
Canada Health Act — Annual Report 2010–2011
Health care insurance plans managed by the Department
of Health and Community Services include the Hospital
Insurance Plan and the Medical Care Plan (MCP). Both
plans are non-profit and publicly administered.
The Hospital Insurance Agreement Act is the legislation that enables the Hospital Insurance Plan. The Act
gives the Minister of Health and Community Services
the authority to make regulations for providing insured
services on uniform terms and conditions to residents
of the province under the conditions specified in the
Canada Health Act and its regulations.
The Medical Care Insurance Act, 1999 empowers the
Minister to administer a plan of medical care insurance
for residents of the province. It provides for the development of regulations to ensure that the provisions of the
statute meet the requirements of the Canada Health Act
as it relates to administering the MCP.
The MCP facilitates the delivery of comprehensive
medical care to all residents of the province by implementing policies, 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 2010–2011.
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 Trans­
parency and Accountability Act (2006), the Department of
Health and Community Services and the eight (8) entities
17
Chapter 3: Newfoundland and Labrador
that report to the Minister, including Regional Health
Authorities, 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 web site (www.gov.nl.ca/
health/publications). The Department’s 2009–2010
Annual Report was tabled in the House of Assembly
in September 2010.
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
2010–2011.
1.3Audit of Accounts
2.2Insured Physician Services
Each year, the province’s Auditor General independently examines provincial public accounts. MCP
expenditures are considered a part of the public
accounts. The Auditor General has full and unrestricted
access to MCP records.
The enabling legislation for insured physician services
is the Medical Care Insurance Act, 1999 and the regulations made thereunder, which include:
The four regional health authorities 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.
• the Medical Care Insurance Insured Services
Regulations;
• the Medical Care Insurance Beneficiaries and
Inquiries Regulations; and
• the Physicians and Fee Regulations.
In 2010–2011, there were 1,096 physicians registered
in the province.
An insured service is defined as one that is listed
in section 3 of the Medical Care Insurance Insured
Services Regulations; medically necessary; and/or
recommended by the Department of Health and
Community Services. There are no limitations on
the services covered, subject to these criteria.
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;
2.0Comprehensiveness
• group immunizations or inoculations carried out
by physicians at the request of the appropriate
authority; and
2.1Insured 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.
18
• 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
Canada Health Act — Annual Report 2010–2011
Chapter 3: Newfoundland and Labrador
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, 2011, 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 added or deleted during
the 2010–2011 fiscal year to the list of insured physician services.
2.3Insured Surgical-Dental Services
The provincial Surgical-Dental Program is a component of the MCP. Surgical-dental treatments provided
to a beneficiary and carried out in a hospital by a
licensed oral surgeon or dentist are covered by MCP
if the treatment is specified in the 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. There is currently
one opted-out dentist.
Canada Health Act — Annual Report 2010–2011
Because the Surgical-Dental Program is a component of
the MCP, management of the program is linked to the
MCP process regarding changes to the list of insured
services.
Addition of a surgical-dental service to the list of
insured services must be approved by the Minister.
2.4
Uninsured Hospital, Physician and
Surgical-Dental Services
Hospital services not covered by MCP include: preferred
accommodation at the patient’s request; cosmetic surgery
and other services deemed to be medically unnecessary;
ambulance or other patient transportation before admission or upon discharge; private duty nursing arranged
by the patient; non-medically required x-rays or other
services for employment or insurance purposes; drugs
(except anti-rejection and AZT drugs) and appliances
issued for use after discharge from hospital; bedside
telephones, radios or television sets for personal, nonteaching 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 noninsured physician services:
• any advice given by a physician to a beneficiary
by telephone;
• the dispensing by a physician of medicines, drugs
or medical appliances and the giving or writing of
medical prescriptions;
• the preparation by a physician of records, reports
or certificates for, or on behalf of, or any communication to, or relating to, a beneficiary;
• any services rendered by a physician to the spouse
and children of the physician;
• any service to which a beneficiary is entitled under
an Act of the Parliament of Canada, an Act of the
Province of Newfoundland and Labrador, an Act
of the legislature of any province of Canada, or
any law of a country or part of a country;
• the time taken or expenses incurred in travelling
to consult a beneficiary;
19
Chapter 3: Newfoundland and Labrador
• ambulance service and other forms of patient
transportation;
• acupuncture and all procedures and services
related to acupuncture, excluding an initial
assessment specifically related to diagnosing the
illness proposed to be treated by acupuncture;
• examinations not necessitated by illness or at
the request of a third party except as specified
by the Department;
• plastic or other surgery for purely cosmetic
purposes, unless medically indicated;
• testimony in a court;
• visits to optometrists, general practitioners and
ophthalmologists solely for determining whether
new or replacement glasses or contact lenses are
required;
• the fees of a dentist, oral surgeon or general
practitioner for routine dental extractions performed in hospital;
• fluoride dental treatment for children under
four years of age;
• excision of xanthelasma;
• circumcision of newborns;
• hypnotherapy;
• medical examination for drivers;
• alcohol/drug treatment outside Canada;
• consultation required by hospital regulation;
• therapeutic abortions performed in the province at
a facility not approved by the College of Physicians
and Surgeons of Newfoundland and Labrador;
• sex reassignment surgery, when not recommended
by the Clarke Institute of Psychiatry;
• in vitro fertilization and OSST (ovarian stimulation
and sperm transfer);
• reversal of previous sterilization procedure;
• surgical, diagnostic or therapeutic procedures not
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.
20
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.
Surgical-dental and other services not covered by the
Surgical-Dental Program include the dentist’s fee and
the oral surgeon’s or general practitioner’s fees for
routine dental extractions in a hospital.
The Medical Care Insurance Act, 1999 provides the
Lieutenant-Governor in Council with the authority to
make regulations prescribing which services are or
are not insured services for the purpose of the Act.
3.0Universality
3.1Eligibility
There were 523,508 people registered with the program
as of March 31, 2011. 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 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
Canada Health Act — Annual Report 2010–2011
Chapter 3: Newfoundland and Labrador
meet the criteria for eligibility as noted above in order to
become eligible.
3.2Other 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
4.1Minimum 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 Inter­
provincial Agreement on Eligibility and Portability
regarding matters pertaining to portability of insured
services in Canada.
Sections 12 and 13 of the Hospital Insurance
Regulations define portability of hospital coverage
during absences both within and outside Canada.
The eligibility policy for insured hospital services is
linked to the eligibility policy for insured physician
services.
Coverage is provided to residents during temporary
absences within Canada. The Government of
Newfoundland and Labrador has entered into
formal agreements (i.e., the Hospital Reciprocal
Billing Agreement) with other provinces and
territories for the reciprocal billing of insured
hospital services. In-patient costs are paid at
standard rates approved by the host province
or territory. In-patient, high-cost procedures and
Canada Health Act — Annual Report 2010–2011
out-patient services are payable based on national
rates agreed to by provincial and territorial health
plans through the Interprovincial Health Insurance
Agreements Coordinating Committee.
Medical services incurred in all provinces (except Quebec)
or territories, are paid through the Medical Reciprocal
Billing Agreement at host province or territory rates.
Claims for medical services received in Quebec are
submitted by the patient to the MCP for payment at host
province rates.
In order to qualify for out-of-province coverage, a
beneficiary must comply with the legislation and
MCP rules regarding residency in Newfoundland
and Labrador. A resident must reside in the province
at least four consecutive months in each 12-month
period to qualify as a beneficiary. Generally, the rules
regarding medical and hospital care coverage during
absences include the following:
• Before leaving the province for extended periods,
a resident must contact the MCP to obtain an outof-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 full-time enrolment in a recognized educational institution located outside the province.
• Persons leaving the province for employment
purposes may receive a certificate for coverage
up to 12 months. Verification of employment
may be required.
• Persons must not establish residence in another
province, territory or country while maintaining
coverage under the Newfoundland MCP.
• For out-of-province trips of 30 days or less, an outof-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.
21
Chapter 3: Newfoundland and Labrador
Insured residents moving permanently to other parts of
Canada are covered up to and including the last day of
the second month following the month of departure.
4.3
Coverage During Temporary Absences
Outside Canada
The province provides coverage to residents during
temporary absences outside Canada. Out-of-country
insured hospital in- and out-patient services are covered
for emergencies, sudden illness, and elective procedures
at established rates. Hospital services are considered
under the Plan when the insured services are provided
by a recognized facility (licensed or approved by the
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. Physician
services are paid at the same rate as would be paid
in Newfoundland and Labrador for the same service.
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.
Coverage is immediately discontinued when residents
move permanently to other countries.
4.4
Prior Approval Requirement
Prior approval is not required for medically necessary
insured services provided by accredited hospitals or
licensed physicians in the other provinces and territories. However, physicians may seek advice on coverage
from the MCP so that patients may be made aware of
any financial implications.
Prior approval is mandatory in order to receive funding
at host country rates if a resident of the province has
to seek specialized hospital care outside the country
because the insured service is not available in Canada.
The referring physicians must contact the Department
for prior approval. If prior approval is granted, the
22
provincial health insurance plan will pay the costs of
services necessary for the patient’s care. Prior approval
is not granted for out-of-country treatment or elective
services if the service is available in the province or elsewhere within Canada. If the services are not available
in Newfoundland and Labrador, they are usually paid
at Ontario rates, or at rates that apply in the province
where they are available.
5.0Accessibility
5.1Access 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 2010, a record investment of $2.7 billion was
allocated for health operations, which signifies
an increase of more than 10 percent over the
previous year. This includes, investments in health
care infrastructure totalling $208.9 million; investments for new construction and redevelopment
totalling $125.1 million, $31.6 million for repairs
and renovations and $52.2 million to purchase new
medical equipment. Funding of $606,000 was also
allocated to enhance the Medical Transportation
Assistance Program.
The government continues its commitment to cancer care and treatment with the implementation of
a new Provincial Colorectal Screening Program. The
investment will amount to $4.3 million over a 3 year
period. In preparation of this, the Government invested
$190,000 in Budget 2010 to develop a provincial wait
time strategy for endoscopy services. The strategy
included a review of the current capacity within the
system and its ability to meet the demands that the
new Colorectal Cancer Screening program will
generate.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Newfoundland and Labrador
Provincial wait time data for the period ending
March 31, 2011, shows that residents of Newfoundland and Labrador are continuing to receive
timely access to the majority of benchmark procedures.
Patients continue to receive timely access to radiation
treatment within the 28 day benchmark. Cardiac bypass
patients are also receiving surgery within the recommended timeframes. Nearly eight out of 10 patients
undergo cataract procedures within 112 days. Patients
continue to access hip and knee replacement surgery
within 182 days in three regions. While wait times for
these procedures continue to be longer in St. John’s, than
elsewhere in the province, demand is also greatest there.
To help address this, approximately $600,000 will be
invested over two years to support the establishment of
a central assessment clinic for patients awaiting hip and
knee replacement in St. John’s. These patients will now
be triaged into three different groups: ready for surgery;
needing additional services, such as pre-surgery physiotherapy or weight reduction; or, needing specialized
medical care prior to surgery.
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.
5.2
RHAs are continually facing challenges in addressing
increased demands due to inflation and increased workload. Higher patient expectations and new technology are
creating new demands for time, resources and funding.
RHAs continue to work with the Department to address
these issues and provide effective, efficient and quality
health services.
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 fee-for-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 regional
health authorities (RHAs) play a significant 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 20, 2013. Physicians are paid via fee
for service, salary or alternate payment plan (APP)
with an increasing interest in APPs as a method of
remuneration.
5.3
Payments to Hospitals
The Department is responsible for funding RHAs for
ongoing operations and capital acquisitions. Funding for
Canada Health Act — Annual Report 2010–2011
Throughout the fiscal year, the RHAs forwarded
additional funding requests to the Department for
any changes in program areas or increased workload
volume. These requests were reviewed and, when
approved by the Department, funded at the end of
each fiscal year. Any adjustments to the annual funding level, such as for additional approved positions or
program changes, were funded based on the implementation date of such increases and the cash flow
requirements.
6.0
Recognition Given to Federal Transfers
Funding provided by the federal government through
the Canada Health Transfer (CHT) and the Canada Social
Transfer (CST) has been recognized and reported by the
Government of Newfoundland and Labrador in the annual
provincial budget, through press releases, government
websites and various other documents. For fiscal year
2010–2011, these documents include:
• the 2010–2011 Public Accounts;
• the Estimates 2010–2011; and
• the Budget Speech 2010.
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.
23
Chapter 3: Newfoundland and Labrador
Registered Persons
1.Number as of March 31st (#).
2006–2007
2007–2008
545,629
506,530
1
2008–2009
2009–2010
2010–2011
514,470
523,433
523,508
Insured Hospital Services Within Own Province or Territory
Public Facilities
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
36
50
51
51
51
743,680,905
798,018,159
880,628,613
964,078,687
1,028,697,016
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
1
1
1
1
1
288,800
307,825
389,375
432,500
660,625
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 ($).
2
Insured Hospital Services Provided to residents in another province or territory
6.Total number of claims, in-patient (#).
7.Total payments, in-patient ($).
8.Total number of claims, out-patient (#).
9.Total payments, out-patient ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
1,736
1,910
1,732
1,595
1,632
15,157,341
16,509,144
15,695,411
16,928,930
21,096,749
34,349
34,159
29,758
25,770
23,156
6,755,412
6,817,250
7,680,172
7,325,977
7,214,089
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11.Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
60
73
90
94
97
92,683
496,719
368,959
123,890
318,203
345
404
400
317
445
934,295
651,841
204,973
272,567
209,257
1. Newfoundland and Labrador completed the re-registration project that commenced in 2006. Thus, the 2007–2008 number represents re-registered residents only.
2. Nursing stations/community clinics not included in previous reports.
24
Canada Health Act — Annual Report 2010–2011
Chapter 3: Newfoundland and Labrador
Insured Physician Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
985
989
1,037
1,075
1,096
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
not available
not available
not available
not available
not available
182,730,000
189,169,000
199,127,000
211,145,000
216,931,000
14.Number of participating physicians (#). 3
17.Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($).
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
139,000
168,000
136,000
147,000
155,000
6,290,000
6,320,000
6,161,000
6,991,000
6,665,000
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
2,100
2,300
2,900
3,100
3,600
130,000
300,000
240,000
157,000
202,000
Insured Surgical-Dental Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
27
25
25
31
29
2,044
885
2,995
290
1,093
123,000
73,000
331,000
28,000
158,000
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
3.
Excludes inactive physicians.Total salaried and fee-for-service.
Canada Health Act — Annual Report 2010–2011
25
26
Canada Health Act — Annual Report 2010–2011
Chapter 3: Prince Edward Island
1.0 Public Administration
1.1 Health Insurance Plan and Public Authority
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.
Following an extensive health system review, the Health
Services Act was enacted and subsequently proclaimed,
which established 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 new governance structure Health PEI is
responsible to:
• provide, or provide for the delivery of, health
services;
• operate and manage health facilities;
• manage the financial, human and other resources
necessary to provide health services and operate
health facilities; and
• perform such other duties as the Minister may
direct.
Canada Health Act — Annual Report 2010–2011
The Hospital Services Insurance Plan, under the authority of the Minister of Health and Wellness, is the
vehicle for delivering hospital care insurance in Prince
Edward Island. The enabling legislation is the Hospital
and Diagnostic Services Insurance Act (1988). The
Medical Services Insurance Plan provides for insured
physician services under the authority of the Health
Services Payment Act (1988). Together, the Plans insure
services as defined under section 2 of the Canada
Health Act.
The Department of Health and Wellness is responsible
for providing policy, strategic and fiscal leadership for
the healthcare system, while Health PEI is responsible
for service delivery and the operation of hospitals, health
centres, manors and mental health facilities. The Public
Service Commission of PEI hires physicians, nurses and
other health related workers.
1.2 Reporting Relationship
An annual report is submitted by the Department to
the Minister responsible who tables it in the Legislative
Assembly. The report provides information about the
operating principles of the Department and its legislative
responsibilities, as well as an overview and description
of the operations of the departmental divisions and
statistical highlights for the year.
Health PEI prepares an annual business plan which
functions as a formal agreement between Health PEI
and the Minister responsible, and documents accomplishments to be achieved over the coming fiscal year.
1.3 Audit of Accounts
The provincial Auditor General conducts annual audits
of the public accounts of 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 November 2010. Public Accounts Volume II
Operating Fund Financial Statements, Details of
Revenues and Expenditures, Financial Statements
of Agencies and Crown Corporations was published
in February 2011.
27
Chapter 3: Prince Edward Island
The provincial Auditor General, through the Audit Act,
has the discretionary authority to conduct further audit
reviews on a comprehensive or program specific basis.
2.0 Comprehensiveness
2.1 Insured Hospital Services
Insured hospital services are provided under the
Hospital and Diagnostic Services Insurance Act (1988).
The accompanying Regulations (1996) define the insured
in- and out-patient hospital services available at no
charge to a person who is eligible. Insured hospital
services include: necessary nursing services; laboratory,
radiological and other diagnostic procedures; accommodations and meals at a standard ward rate; formulary
drugs, biologicals and related preparations prescribed
by an attending physician and administered in hospital;
operating room, case room and anaesthetic facilities;
routine surgical supplies; and radiotherapy and physiotherapy services performed in hospital.
The process to add a new hospital service to the list of
insured services involves extensive consultation and
negotiation between the Department, Health PEI and key
stakeholders. The process involves the development of
a business plan which, when approved by the Minister,
would be taken to Treasury Board for funding approval.
Executive Council (Cabinet) has the final authority in
adding new services.
2.2 Insured Physician Services
The enabling legislation that provides for insured
physician services is the Health Services Payment Act
(1988).
Insured physician services are provided by medical
practitioners licensed by the College of Physicians and
Surgeons. The total number of practitioners, including
locums, who billed the Medical Services Insurance
Plan as of March 31, 2011, was 399.
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
28
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, 2011, no physicians had opted out of
the Medical Services Insurance Plan.
Any basic health services rendered by physicians that
are medically required are covered by the Medical
Services Insurance Plan. These include most physicians’ services in the office, at the hospital or in the
patient’s home; medically necessary surgical services,
including the services of anaesthetists and surgical assistants where necessary; obstetrical services,
including pre- and post-natal care, newborn care or
any complications of pregnancy such as miscarriage
or caesarean section; certain oral surgery procedures
performed by an oral surgeon when it is medically
required, with prior approval that they be performed
in a hospital; sterilization procedures, both female and
male; treatment of fractures and dislocations; and certain insured specialist services, when properly referred
by an attending physician.
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. 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:
Canada Health Act — Annual Report 2010–2011
Chapter 3: Prince Edward Island
• services that persons are eligible for under other
provincial or federal legislation;
• mileage or travel, unless approved by Health PEI;
• advice or prescriptions by telephone, except anticoagulant therapy supervision;
• telephone consultation except by internists and
orthopedic surgeons, provided the patient was not
seen by that internist or orthopedic surgeon 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
communications, except a certificate of committal
to a psychiatric, drug or alcoholism facility;
• testimony in court;
• travel clinic and expenses;
• surgery for cosmetic purposes unless medically
required;
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 2010–2011 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.
• dental services other than those procedures
included as basic health services;
3.0 Universality
• dressings, drugs, vaccines, biologicals and related
materials;
3.1 Eligibility
• eyeglasses and special appliances;
• chiropractic, podiatry, optometry, chiropody,
osteopathy, naturopathy, and similar treatments;
• physiotherapy, psychology, audiology, 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
Canada Health Act — Annual Report 2010–2011
The Health Services Payment Act and regulations,
section 3, define eligibility for the Medical Services
Insurance Plan. The 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 members of the Canadian Forces, Royal Canadian
Mounted Police (RCMP), inmates of federal penitentiaries and those eligible for certain services under other
government programs, such as Workers’ Compensation
or the Department of Veterans Affairs’ programs.
Ineligible residents may become eligible in certain circumstances. Members of the Canadian Forces or RCMP
29
Chapter 3: Prince Edward Island
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 released 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, 2011, was 146,049.
3.2 Other Categories of Individual
Foreign students, temporary workers, refugees and
Minister’s Permit holders are not eligible for health
and medical coverage.
4.0 Portability
4.1 Minimum Waiting Period
Insured persons who move to Prince Edward Island are
eligible for health insurance on the first day of the third
month following the month of arrival in the province.
4.2 Coverage During Temporary Absences
in Canada
Persons absent each year for winter vacations and
similar situations involving regular absences must reside
in Prince Edward Island for at least six months plus a
day each year in order to be eligible for sudden illness
and emergency services while absent from the province,
as allowed under section 5(1)(e) of the Health Services
Payment Act.
30
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.
For Island residents travelling outside Canada, coverage
for emergency or sudden illness will be provided at Prince
Edward Island rates only, in Canadian currency. Residents
are responsible for paying the difference between the full
amount charged and the amount paid by the Department.
4.4
Prior Approval Requirement
Prior approval is required from Health PEI before
receiving non-emergency, out-of-province medical or
hospital services. Island residents seeking such required
services may apply for prior approval through a Prince
Edward Island physician. Full coverage may be provided
for (Prince Edward Island insured) non-emergency or
elective services, provided the physician completes an
application to Health PEI. Prior approval is required
from the Medical Director of Health PEI to receive outof-country hospital or medical services not available
in Canada.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Prince Edward Island
5.0 Accessibility
5.1 Access to Insured Health Services
Both of Prince Edward Island’s hospital and medical
services insurance plans provide services on uniform
terms and conditions on a basis that does not impede
or preclude reasonable access to those services by
insured persons.
Prince Edward Island has a publicly administered and
funded health system that guarantees universal access
to medically necessary hospital and physician services
as required by the Canada Health Act.
The teleradiology program initiated in 2009 to help
reduce wait times for diagnostic imaging in Prince
Edward Island continued until January 2011. The
addition of new digital mammography units last year
has now been enhanced with a new centralized phone
number and booking system that is being installed.
Hours of service at screening sites have also been
increased, which should result in a significant reduction in wait times for the provincial breast screening
program.
Prince Edward Island implemented the first phase of a
three-phased provincial organized stroke care model
in April of 2010. This model promotes a coordinated
approach to early assessment, mobilization and rehabilitation for every patient who can benefit. This first
phase created a Provincial Stroke Care Coordinator
position; instituted an acute in-patient stroke unit
and stroke rehabilitation unit at the Queen Elizabeth
Hospital; and created provincial secondary prevention
services at Prince County Hospital.
This past year hemodialysis services were enhanced
across the province. A new provincial Cancer Patient
Navigation program was also implemented, providing
necessary support and assistance to cancer patients
and their families in navigating the health-care system.
The major multi-year redevelopment project at our
provincial referral hospital reached several significant milestones this past year. The new Emergency
Department at the Queen Elizabeth Hospital opened
in June 2010. In addition, construction began on
the Ambulatory Care Centre at the Queen Elizabeth
Hospital.
Over the past twelve months the new Health Centre in
O’Leary opened which provides enhanced health care
services to surrounding communities. Also, as part of a
manor replacement strategy construction began on new
manors in Alberton and Souris.
Canada Health Act — Annual Report 2010–2011
The PEI Family Medicine Residency Program has provided ongoing training opportunities to medical school
graduates who are training as family physicians. The
intent is to better integrate our medical students so that
they will want to stay and practice in the province. The
first five family medicine residents began in their two
year training program on the Island in June 2009, with
five new residents each year thereafter, bringing full
complement of family medical residents to ten.
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 three year Physician
Master Agreement between the PEI Medical Society, on
behalf of Island physicians, and the provincial government, was effective April 1, 2007 to March 31, 2010.
It remains in effect until a new agreement is reached.
The legislation governing payments to physicians and
dentists for insured services is the Health Services
Payment Act.
Many physicians continue to work on a fee-for-service
basis. However, alternate payment plans have been
developed and some physicians receive salary, contract
and sessional payments. Alternate payment modalities are growing and seem to be the preference for new
graduates. Currently, 67 percent of PEI’s complement of
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.
31
Chapter 3: Prince Edward Island
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 2010–2011
Annual Budget and in the 2010–2011 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 2010–2011 Annual Report.
32
Canada Health Act — Annual Report 2010–2011
Chapter 3: Prince Edward Island
Registered Persons
1.Number as of March 31st (#).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
145,047
146,518
142,305
143,238
146,049
Insured Hospital Services Within Own Province or Territory
Public Facilities
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
7
7
7
7
7
133,253,200
137,982,600
151,304,500
161,439,600
172,100,500
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
4.Number of private for-profit facilities
providing insured health services (#).
not applicable
not applicable
not applicable
not applicable
not applicable
5.Payments to private for-profit facilities
for insured health services ($).
not applicable
not applicable
not applicable
not applicable
not applicable
2.Number (#).
3.Payments for insured health services ($).
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
2,003
2,253
2,591
2,692
2,564
17,510,188
19,448,899
20,582,454
26,099,326
25,159,408
15,675
17,867
18,488
17,147
16,763
3,345,624
4,292,114
5,290,630
5,385,508
5,286,499
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 ($).
35
28
34
46
29
105,268
49,616
113,901
157,547
70,768
96
137
122
127
113
16,179
27,533
33,919
65,114
44,213
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
Canada Health Act — Annual Report 2010–2011
33
Insured Physician Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
228
221
256
240
242
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 ($).
56,063,644
18.Total payments for services provided by
physicians paid through fee-for-service ($).
34,543,095
2
61,974,581
61,445,780
2
34,973,359
2
41,123,808
72,874,951
45,959,450
2
62,670,303
2
49,332,788
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
73,399
77,992
77,830
79,139
80,559
5,221,586
6,035,626
5,998,751
6,386,325
6,247,907
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
746
562
1,053
786
684
27,899
23,979
52,601
39,137
31,729
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
3
3
3
3
2
442
364
424
451
352
106,708
95,749
149,794
171,901
137,566
1. Total does not include locums or visiting specialists.
2. Reflects payments made through claim submissions and salary allocations.
34
Canada Health Act — Annual Report 2010–2011
Chapter 3: NOVA SCOTIA
The Department of Health and Wellness is directly
responsible for physician and pharmaceutical services,
emergency health, continuing care, and many other
insured and publicly funded health programs and
services.
Nova Scotia
Introduction
On January 12, 2011, the Departments of Health and
Health Promotion and Protection merged into the
Department of Health and Wellness to provide better
health care to Nova Scotians. The merger served to
streamline operations and ensure better integration
between the prevention and treatment sides of health
care. The Nova Scotia Department of Health and
Wellness mission is, “Working together to empower
individuals, families, partners, and communities to
promote, improve, and maintain the health of Nova
Scotians through a proactive and sustainable health
system.” 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, Chapter 6 of the Acts of 2000,
established the province’s nine district health authorities
(DHAs) and their community-based supports, community
health boards (CHBs). DHAs are responsible for governing, planning, managing, delivering and monitoring
health services within each district, and for providing
planning support to the CHBs. Services delivered by the
DHAs include acute and tertiary care, mental health,
and addictions.
The province’s 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.
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.
Canada Health Act — Annual Report 2010–2011
Nova Scotia faces a number of challenges in the delivery
of health care services. Nova Scotia’s population is aging.
Approximately 16% 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 basket of publicly insured services to include home care, longterm 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 in Nova Scotia.
Despite these ever increasing pressures and challenges,
Nova Scotia continues to be committed to the delivery
of medically necessary services consistent with the
principles of the Canada Health Act.
Additional information related to health care in Nova
Scotia may be obtained from the Department of Health
and Wellness website at www.gov.ns.ca/DHW.
1.0 Public Administration
1.1Health 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) Plan. 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 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 and Medavie
Blue Cross entered into a service level agreement, effective August 1, 2005. Under the agreement, Medavie is
35
Chapter 3: NOVA SCOTIA
responsible for operating and administering programs
contained under MSI, Pharmacare Programs and Health
Card Registration Services.
2.0Comprehensiveness
1.2
Nine district health authorities and the IWK Health
Centre (Women and Children’s Tertiary Care Hospital)
deliver insured hospital services to both in- and outpatients in Nova Scotia.
Reporting Relationship
Medavie is obliged to provide reports to the Department
under various Statements of Requirements for each
Business Service Description as listed in the contract.
Medavie is audited every year on various areas of
reporting. Every year there is a compliance audit.
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.
1.3Audit of Accounts
The Auditor General audits all expenditures of the
Department of Health and Wellness. The Department
of Health and Wellness has a service level agreement
in place with Medavie Blue Cross. An annual audit
is performed on this agreement, including Medicare,
Pharmacare and Health Card Registration, which has
been recommended by the Auditor General’s office.
All long-term care facilities, home care and home support agencies are required to provide the Department
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.
1.4Designated Agency
Medavie Blue Cross Care administers and has the
authority to receive monies to pay physician accounts
under a service level agreement with the Department of
Health and Wellness. Medavie Blue Cross Care receives
written authorization from the Department for the
physicians to whom it may make 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 Medavie Blue Cross Care system development for
MSI and Pharmacare is controlled through a joint
committee. All MSI and Pharmacare transactions are
subject to a review by the Office of the Auditor General.
36
2.1Insured Hospital Services
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.
Insured in-patient services include:
• accommodation and meals at the standard ward
level;
• necessary nursing services;
• laboratory, radiological and other diagnostic
procedures;
• drugs, biologicals and related preparations, when
administered in a hospital;
• routine surgical supplies;
• use of operating room(s), case room(s) and anaesthetic services;
• use of radiotherapy and physiotherapy services for
inpatients, where available; and
• blood or therapeutic blood fractions.
Out-patient services include:
• laboratory and radiological examinations;
• diagnostic procedures involving the use of
radio-pharmaceuticals;
• electroencephalographic examinations;
• use of occupational and physiotherapy facilities,
where available;
• necessary nursing services;
• drugs, biologicals and related preparations;
• blood or therapeutic blood fractions;
• hospital services in connection with most minor
medical and surgical procedures;
• day-patient diabetic care;
Canada Health Act — Annual Report 2010–2011
Chapter 3: NOVA SCOTIA
• services provided by the Nova Scotia Hearing
and Speech Clinics, where available;
• ultrasonic diagnostic procedures;
Wellness. On an as needed basis, new specific fee codes
are approved that represent enhancements, new technologies or new ways of delivering a service.
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 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.
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.
2.2Insured Physician Services
2.3Insured Surgical-Dental 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.
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 2010–2011,
26 dentists were paid through the MSI Plan for providing
insured surgical-dental services.
• home parenteral nutrition, where available; and
• haemodialysis and peritoneal dialysis, where
available.
As of March 31, 2011, 2,434 physicians and 26 dentists
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, 2011, 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.
Services were added to the list of insured physician
services in 2010–2011. A complete list can be obtained
from the Nova Scotia Department of Health and
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 and 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
1. Emergency/unexpected requirements may be considered at any time throughout the fiscal year.
Canada Health Act — Annual Report 2010–2011
37
Chapter 3: NOVA SCOTIA
and Wellness for the addition of a new procedure. The
Department of Health and Wellness, in consultation
with specific experts in the field, renders the decision
as to whether or not the new procedure becomes an
insured service.
“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 when and 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;
• telephones;
• televisions;
• drugs and biologicals ordered after discharge
from hospital;
• cosmetic surgery;
• reversal of sterilization procedures;
• surgery for sex reassignment;
• in-vitro fertilization;
• procedures performed as part of clinical
research trials;
• services such as gastric bypass for morbid obesity,
breast reduction/augmentation and newborn
circumcision;2 and
• services not deemed medically necessary that
are required by third parties, such as insurance
companies.
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,
electromyogram or electroencephalogram, unless
the physician is a specialist in the appropriate
specialty;
• cosmetic surgery;
• acupuncture;
• reversal of sterilization; and
• in-vitro fertilization.
Major third party agencies 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
the 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
2. These services may be insured when approved as special consideration for medical reasons only.
38
Canada Health Act — Annual Report 2010–2011
Chapter 3: NOVA SCOTIA
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.
3.0Universality
3.1Eligibility
Eligibility for insured health care services in Nova
Scotia is outlined under section 2 of the Hospital
Insurance Regulations made pursuant to section 17
of the Health Services and Insurance Act. All residents
of Nova Scotia are eligible. A resident is defined as
anyone who is legally entitled to stay in Canada and
who makes his or her home and is ordinarily present
in Nova Scotia.
A person is considered to be “ordinarily present” in
Nova Scotia if the person:
• makes his or her permanent home in Nova Scotia;
• is physically present in Nova Scotia for at least
183 days in any calendar year (short term
absences under 30 days, within Canada, are
not monitored); and
• is a Canadian citizen or “Permanent Resident” as
defined by Citizenship and Immigration Canada.
Persons moving to Nova Scotia from another Canadian
province will normally be eligible for Medical Services
Insurance (MSI) on the first day of the third month
following the month of their arrival. Persons moving permanently to Nova Scotia from another country
are eligible on the date of their arrival in the province,
provided they are Canadian citizens or hold “Permanent
Resident” status as defined by Citizenship and Immi­
gration Canada.
Members of the RCMP, members of the Canadian Forces,
and federal inmates are ineligible for MSI coverage.
When their status changes, they immediately become
eligible for provincial Medicare.
There were no changes to eligibility requirements in
2010–2011.
In 2010–2011, the total number of residents registered
with the health insurance plan was 988,585.
Canada Health Act — Annual Report 2010–2011
3.2Other Categories of Individuals
The following persons may also be eligible for insured
health care services in Nova Scotia once they meet the
specific eligibility criteria for their situations:
Immigrants: Persons moving from another country to
live permanently in Nova Scotia are eligible for health
care on the date of arrival. They must possess a landed
immigrant document. These individuals, formerly
called “landed immigrants,” are now referred to as
“Permanent Residents.”
Convention Refugees and Non-Canadians married
to Canadian Citizens/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 2010–2011, there were 31,314 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.
39
Chapter 3: NOVA SCOTIA
In 2010–2011, there were 2,946 individuals with
Employment Authorizations covered under the health
care insurance plan.
Study Permits: Persons moving to Nova Scotia from
another country and who possess a Study Permit will
be eligible for MSI on the first day of the thirteenth
month following the month of their arrival, provided
they have not been absent from Nova Scotia for more
than 31 consecutive days, except in the course of their
studies. MSI coverage is extended for a maximum of
12 months at a time and only for services received
within Nova Scotia. Each year, a copy of their renewed
immigration document must be presented and a declaration signed. Dependants of such persons, who are
legally entitled to remain in Canada, will be granted
coverage on the same basis once the student has gained
entitlement.
In 2010–2011, there were 1,123 individuals with
Student Authorizations covered under the health care
insurance plan.
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. Quebec is the only province
that does not participate in the medical reciprocal agreement. Nova Scotia pays for services provided by Quebec
physicians to Nova Scotia residents at Quebec rates if
the services are insured in Nova Scotia. The majority of
such claims are received directly from Quebec 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 2010–2011 for in- and outpatient hospital services received in other provinces and
territories was $24,592,207.
Nova Scotia pays the host province rates for insured
services in all reciprocal billing situations.
Refugees: Refugees are eligible for MSI if they possess
either a work permit or study permit.
There were no changes made in Nova Scotia in
2010–2011 regarding in-Canada portability.
4.0Portability
4.3
4.1Minimum 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.
40
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 the 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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: NOVA SCOTIA
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 2010–2011 regarding out-of-Canada portability. The
total amount spent in 2010-2011 for insured in-patient
services provided outside of Canada was $788,368.
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
5.1Access 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 December 2010 the province announced the Better
Care Sooner plan. The plan will improve the quality of
emergency care, reduce overcrowding and wait times for
patients in emergency rooms, and provide better health
care for families. This will be done through several focus
areas, including better access to health professionals,
streamlines patient-centred emergency care, better
care for seniors 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 Department has worked with system partners to
address several other areas of health care access. This
has included establishing an intermediate care unit,
new rapid assessment unit, and new medicine beds for
Capital District Health Authority. Nova Scotia will also
be expanding pre-hab services to three more sites in
the province, and expanded of full-field mammography
at eleven fixed sites. There was also the establishment
of shared stroke units in Pictou County Health Authority
and Guysborough Antigonish District Health Authority,
as well as Colchester East Hants Health Authority and
Cumberland Health Authority.
Access to Insured Physician and Surgical-Dental Services
In 2010–2011, 2434 physicians and 26 dentists actively
provided insured services under the Canada Health Act
or provincial legislation. Innovative funding solutions
such as block funding and personal services contracts
have enhanced recruitment.
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
3. With Department of Health support, the Capital District Health Authority has committed to province an additional 430 arthroplasties on a yearly basis commencing
in part in November 2009.
Canada Health Act — Annual Report 2010–2011
41
Chapter 3: NOVA SCOTIA
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 2010–2011,
approximately 26 percent of physicians were remunerated exclusively through alternative funding.
Approximately 67 percent of physicians in Nova
Scotia receive all or a portion of their remuneration
through alternative funding mechanisms.
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.
In 2010–2011, total payments to physicians for
insured services in Nova Scotia were $661,968,168.
The Department of Health and Wellness paid an
additional $7,426,414 for insured physician services
provided to Nova Scotia residents outside the province,
but within Canada.
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. The agreement expired on March 31, 2011 and negotiations are
underway for contract renewal.
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 (9) 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 & the
IWK that replaced the former regional health boards.
The DHAs/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 to hospitals for insured hospital
services.
In 2010–2011, there were 2960 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
$1.56 billion.
6.0 Recognition Given to
Federal Transfers
In Nova Scotia, the Health Services and Insurance
Act acknowledges the federal contribution regarding
the financing of insured hospital services and insured
health services provided to provincial residents. The
residents of Nova Scotia are aware of ongoing federal
contributions to Nova Scotia health care through the
Canada Health Transfer (CHT) as well as other federal
funds through press releases and media coverage.
The Government of Nova Scotia also recognized the federal contribution under the CHT in various published
documents, including the following documents released
in 2010–2011:
• Public Accounts 2010–2011; and
• Budget Estimates and Supplementary Detail
2011–2012.
42
Canada Health Act — Annual Report 2010–2011
Chapter 3: NOVA SCOTIA
Registered Persons
1.Number as of March 31st (#).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
965,044
970,450
975,206
981,922
988,585
Insured Hospital Services Within Own Province or Territory
Public Facilities
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
35
35
35
35
35
1,301,306,116
1,367,828,540
1,406,145,241
1,531,561,311
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
4.Number of private for-profit facilities
providing insured health services (#). 5
0
0
0
0
0
5.Payments to private for-profit facilities
for insured health services ($).
not available
not available
not applicable
not applicable
not applicable
2.Number (#).
3.Payments for insured health services ($). 3
Private For-Profit Facilities
4
1,560,236,537
Insured Hospital Services Provided to residents in another province or territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
2,154
2,257
2,310
2,089
1,946
14,502,141
16,726,553
15,924,363
16,289,798
13,614,172
41,729
42,569
42,089
39,443
38,261
8,269,002
8,946,688
11,558,634
11,180,204
10,978,035
6.Total number of claims, in-patient (#).
7.Total payments, in-patient ($).
8.Total number of claims, out-patient (#).
9.Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
not available
not available
not available
not available
not available
727,586
1,257,620
1,190,016
1,286,181
788,368
12.Total number of claims, out-patient (#).
not available
not available
not available
not available
not available
13.Total payments, out-patient ($).
not available
not available
not available
not available
not available
11.Total payments, in-patient ($).
3. Payments are made to acute care facilities/DHAs only.
4. 2009–2010 includes payments to the DHAs for Care Coordination as program was integrated with the DHAs in the fiscal year.
5. Scotia Surgery is not considered private, it is classified as a hospital (funded by the Department of Health).
Canada Health Act — Annual Report 2010–2011
43
Chapter 3: NOVA SCOTIA
Insured Physician Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
2,282
2,290
2,343
2,401
2,434
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
not applicable
not applicable
not applicable
not applicable
17.Total payments for services provided
by physicians paid through all payment
methods ($).
581,817,423
555,659,788
598,546,450
637,434,810
661,968,168
18.Total payments for services provided by
physicians paid through fee-for-service ($).
255,007,711
258,751,069
266,174,648
301,217,024
301,629,014
14.Number of participating physicians (#).
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
205,237
212,404
215,490
197,580
195,538
7,091,572
7,606,977
7,671,840
7,362,277
7,426,414
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
2,931
2,701
3,051
3,418
3,092
153,937
134,729
161,555
200,452
169,312
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#). 6
25.Total payments ($). 7
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
29
27
29
55
26
5,321
5,831
6,254
6,536
6,913
1,122,126
1,215,333
1,374,645
1,380,344
1,459,608
6. Total services includes block funded dentists.
7.
Total payments does not include block funded dentists.
44
Canada Health Act — Annual Report 2010–2011
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 collaboration, New
Brunswick’s health care system continued to provide
excellent and trusted care to the public it served during
2010–2011, while remaining committed to the principles of public administration, comprehensiveness,
universality, portability and accessibility in health care
services—the principles that form the foundation of the
Canada Health Act.
For information about the Ministry’s programs and
services, please visit the Ministry of Health website
at http://www.gnb.ca/0051/index-e.asp
1.0 Public Administration
1.1Health 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 what 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 2010–2011
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.
1.3Audit 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 Branch was
established to independently review and evaluate
departmental activities as a service to all levels
of management.
2.0Comprehensiveness
2.1Insured 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,
45
Chapter 3: NEW BRUNSWICK
physiotherapy); and services provided by professionals
within the facility.
Insured out-patient services include: laboratory and
diagnostic procedures; mammography; and the hospital component of available out-patient services for
maintaining health, preventing disease and helping
diagnose/treat any injury, illness or disability, excluding
those related to the provision of drugs or third party
diagnostic requests.
Society and the Department. The decision to add a
new service is usually based on conformity to “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.
No services were added during this reporting period.
2.2Insured Physician Services
The Medical Services Payment Act and corresponding
regulations provide for insured physician services. As
of March 31, 2011 there were 1588 physicians in New
Brunswick. No physicians rendering health care services
have elected to completely 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 the claim form that the services have
been received and forward 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:
Schedule 4 of Regulation 84-20 under the Medical
Services Payment Act identifies the insured surgicaldental 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.
• they have opted out and charge fees above the
Medicare tariff;
As of March 31, 2011, there were 99 OMSs and dentists
registered in New Brunswick
• in accepting services under these conditions, the
patient waives all rights to Medicare reimbursement;
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.
• 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
46
2.3Insured Surgical-Dental Services
2.4
Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital services include: patent medicines;
take-home drugs; third-party requests for diagnostic
services; visits to administer drugs; vaccines; sera or
biological products; televisions and telephones; preferred accommodation at the patient’s request; and
hospital services directly related to services listed
under Schedule 2 of the Regulation under the Medical
Services Payment Act. Services are not insured if provided to those entitled under other statutes.
The services listed in Schedule 2 of New Brunswick
Regulation 84-20 under the Medical Services Payment
Canada Health Act — Annual Report 2010–2011
Chapter 3: NEW BRUNSWICK
Act are specifically excluded from the range of entitled
medical services under Medicare. They are as follows:
• electrocardiogram (E.C.G.) where not performed
by a specialist in internal medicine or paediatrics;
• elective plastic surgery or other services for
cosmetic purposes;
• laboratory procedures not included as part of an
examination or consultation fee;
• correction of inverted nipple;
• refractions;
• breast augmentation;
• 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;
• 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
was 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;
• 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 the newborn;
• reversal of vasectomies;
• second and subsequent injections for impotence;
• reversal of tubal ligations;
• intrauterine insemination;
• advice or prescription renewal by telephone which
is not specifically provided for in the Schedule of
Fees;
• 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;
• examination of medical records or certificates at the
request of a third party, or other services required
by hospital regulations or medical by-laws;
• 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 provided by a medical practitioner
or an oral and maxillofacial surgeon;
• services that are generally accepted within New
Brunswick as experimental or that are provided
as applied research;
• services that are provided in conjunction with,
or in relation to, the services referred to above;
• testimony in a court or before any other tribunal;
• immunization, examinations or certificates for
purpose of travel, employment, emigration,
insurance or at the request of any third party;
• services provided by medical practitioners or
oral and maxillofacial surgeons to members of
their immediate family;
• psychoanalysis;
Canada Health Act — Annual Report 2010–2011
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.,
enhanced medical goods and services such as intraocular lenses, fibreglass casts, etc.), 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. Once a decision to de-insure
is reached, the Medical Services Payment Act dictates
47
Chapter 3: NEW BRUNSWICK
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 2010–2011, 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, 2011,
there were 748,352 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
48
province. Proper documentation is required
(immigration and citizenship documentation)
and decisions on coverage/residency are
reviewed on a case-by-case basis.
Residents who are not eligible for Medicare coverage
include:
• regular members of the Canadian Armed Forces;
• members of the Royal Canadian Mounted Police;
• 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.
3.2Other 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 2010–2011
Chapter 3: NEW BRUNSWICK
4.0Portability
4.1Minimum 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 and no
exemptions can be made.
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
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.
Mobile Workers
Mobile Workers are residents whose employment
requires them to travel outside the province (e.g., pilots,
truck drivers, etc.). Certain guidelines must be met to
receive Mobile Worker designation. They are as follows:
• health coverage is not received elsewhere.
Canada Health Act — Annual Report 2010–2011
49
Chapter 3: NEW BRUNSWICK
• 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 outof-country must supply the following information and
documentation:
• a letter of request from the New Brunswick resident with their signature, detailing their absence,
including Medicare number, address, departure
and return dates, destination, forwarding address,
and reason for absence; and
• a copy of a contractual agreement between employee
and employer indicating start and end dates of
employment.
Contract Worker status is assigned up to a maximum
of two years. Any further requests for Contract Worker
status must be forwarded to the Director of Medicare
Eligibility and Claims for approval on an individual
basis.
Students
Those in full-time attendance at a university or other
approved educational institution in another country will
be granted coverage for a twelve month period that is
renewable, provided they comply with the following:
• proof of enrolment be provided;
• contact Medicare once every twelve months to
retain eligibility;
• permanent residence is not established outside
New Brunswick; and
• health coverage is not received elsewhere.
50
Insured residents who receive insured emergency services out-of-country are eligible to be reimbursed $100
per day for in-patient stay 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.
4.4
Prior Approval Requirement
Medicare may cover out-of-country services that are
not available in Canada on a pre-approval basis only.
Residents may opt to seek non-emergency out-of-country
services; however, those who receive such services will
assume responsibility for the total cost.
New Brunswick residents may be eligible for reimbursement if they receive elective medical services outside the
country, provided the following requirements are met:
• the required service/equivalent or alternate service
must not be available in Canada;
• 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-of-country 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
Canada Health Act — Annual Report 2010–2011
Chapter 3: NEW BRUNSWICK
• 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.
5.0Accessibility
5.1Access 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.
5.3
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.
6.0 Recognition Given to
Federal Transfers
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.
Payments to Hospitals
The legislative authorities governing payments to hospital facilities in New Brunswick are the Hospital Act,
which governs the administration of hospitals, and the
Hospital Services Act, which governs the financing of
hospitals. The Regional Health Authorities Act provides
for the delivery and administration of health services in
defined geographic areas within the province.
Canada Health Act — Annual Report 2010–2011
51
Chapter 3: NEW BRUNSWICK
Registered Persons
1.Number as of March 31st (#).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
738,651
740,845
742,974
744,048
748,352
Insured Hospital Services Within Own Province or Territory
Public Facilities
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
50
50
53
56
57
1,290,887,880
1,372,911,800
1,449,216,237
1,590,399,994
1,616,340,008
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
4.Number of private for-profit facilities
providing insured health services (#). 1
not applicable
not applicable
not applicable
not applicable
not applicable
5.Payments to private for-profit facilities
for insured health services ($). 1
not applicable
not applicable
not applicable
not applicable
not applicable
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 ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
4,363
4,363
3,919
4,036
4,537
42,267,067
42,267,067
37,772,992
37,343,696
44,337,432
51,406
51,406
46,824
49,005
44,444
11,316,103
11,316,103
12,858,195
14,912,717
14,186,848
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11.Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
211
209
196
251
245
741,599
726,650
753,104
556,678
607,147
1,122
1,073
1,430
1,575
1,805
358,594
441,575
561,855
883,980
798,355
1. There are no private for-profit facilities operating in New Brunswick.
52
Canada Health Act — Annual Report 2010–2011
Chapter 3: NEW BRUNSWICK
Insured Physician Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
1,399
1,453
1,500
1,571
1,588
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
17.Total payments for services provided
by physicians paid through all payment
methods ($). 3
400,481,139
421,547,901
441,197,899
505,899,089
538,111,685
18.Total payments for services provided by
physicians paid through fee-for-service ($).
244,907,268
254,454,602
260,939,796
273,030,951
279,663,511
14.Number of participating physicians (#). 2
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
192,544
213,710
197,023
266,918
209,868
11,125,487
11,998,933
11,607,119
16,206,261
11,965,539
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
6,047
5,990
4,175
5,885
4,610
417,942
487,679
341,618
440,957
568,937
Insured Surgical-Dental Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
25
21
26
26
14
2,472
2,962
3,323
3,363
2,722
502,913
598,383
571,175
385,796
367,905
23.Number of participating dentists (#). 4
24.Number of services provided (#).
25.Total payments ($).
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 2010–2011,
of the 99 dentists and OMSs registered, 14 billed the Medical Services Plan.
Canada Health Act — Annual Report 2010–2011
53
54
Canada Health Act — Annual Report 2010–2011
Chapter 3: QUEBEC
2.0Comprehensiveness
2.1Insured Hospital Services
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 Department 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.
1.3Audit of Accounts
Both plans (the Quebec hospital insurance plan and the
Quebec health insurance plan) are operated on a nonprofit basis. All books and accounts are audited by the
auditor general of the province.
Canada Health Act — Annual Report 2010–2011
Insured in-patient services include the following:
standard ward accommodation and meals; necessary
nursing services; routine surgical supplies; diagnostic services; use of operating rooms, delivery rooms
and anaesthetic facilities; medication; prosthetic and
orthotic devices that can be integrated with the human
body; biological products and related preparations;
use of radiotherapy, radiology and physiotherapy
facilities; and services rendered by hospital staff.
Out-patient services include the following: clinical
services for psychiatric care; electroshock, insulin and
behaviour therapies; emergency care; minor surgery
(day surgery); radiotherapy; diagnostic services; physiotherapy; occupational therapy; inhalation therapy,
audiology, speech therapy and orthoptic services;
and other services or examinations required under
Quebec legislation.
Other insured services are: mechanical, hormonal
or chemical contraception services; surgical sterilization services (including tubal ligation or vasectomy);
reanastomosis of the fallopian tubes or vas deferens;
and extraction of a tooth or root when the patient’s
health status makes hospital services necessary.
The MSSS administers an ambulance transportation
program that is free of charge to persons aged 65
or older.
In addition to basic insured health services, the Régie
also covers the following, with some limitations, for
certain residents of Quebec, as defined by the Health
Insurance Act (R.S.Q. c. A-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
2010–2011, the drug insurance plan covers 3.3 million
insured persons.
55
Chapter 3: Quebec
2.2Insured Physician Services
Services insured under this plan include medical and
surgical services that are provided by physicians and
that 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.
2.3Insured 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 rendered 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 rendered 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 rendered
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
56
substances and the examination performed at that time;
mammography used for detection purposes, unless this
service is rendered on 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 rendered in a hospital
centre; ultrasonography, unless this service is rendered
in a hospital centre or, for obstetrical purposes, in a local
community service centre (CLSC) recognized for that
purpose; any radiological or anaesthetic service provided
by a physician if required with a view to 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 rendered by a physician to a patient
between 18 and 65 years of age, unless that individual
is the holder of a claim booklet, for colour blindness or a
refractive error, in order to provide or renew a prescription for eyeglasses or contact lenses.
3.0Universality
3.1Eligibility
Registration with the hospital insurance plan is not
required. Registration with the Régie de l’assurance
maladie du Québec 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.
3.2Other 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
Canada Health Act — Annual Report 2010–2011
Chapter 3: QUEBEC
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 Department of Education),
persons from outside Canada who are eligible under
an agreement or accord reached with a country or
an international organization, and refugees. Persons
from outside Canada who have work permits and are
living in Quebec for the purpose of holding an office
or employment for a period of more than six months
become eligible for the plan following a waiting period.
4.0Portability
4.1Minimum Waiting Period
Persons settling in Quebec after moving from another
province of Canada are entitled to coverage under the
Quebec health insurance plan when they cease to be
entitled to benefits from their province of origin, provided they register with the Régie.
4.2
Coverage During Temporary Absences
In Canada
If living outside Quebec in another province or territory
for 183 days or more, and provided they notify the Régie
of this, students and full-time unpaid trainees may retain
their status as residents of Quebec: students for a maximum of four consecutive calendar years, and full-time
unpaid trainees for a maximum of two consecutive
calendar years.
This is also the case for persons living in another
province or territory who are temporarily employed
or working on contract there. Their resident status
can be maintained for no more than two consecutive
calendar years.
Persons directly employed or working on contract outside of Quebec for a company or corporate body with its
headquarters or a place of business in Quebec, to which
they report directly, or employed by the federal government and posted outside Quebec, also retain their status
as a resident of the province. The same is true of persons who remain outside the province 183 days or more,
but less than 12 months within a calendar year, provided
such absence occurs only once every seven years.
Canada Health Act — Annual Report 2010–2011
The costs of medical services received in another province or territory of Canada are reimbursed at the amount
actually paid or the rate that would have been paid by
the Régie for such services in Quebec, whichever is less.
However, Quebec has negotiated a permanent arrangement with Ontario to pay Ottawa doctors at the Ontario
fee rate for specialized services that are not available in
the Outaouais region. This agreement came into effect
on November 1, 1989. The Régie covers the amount it
would have paid for the same services in Quebec. The
Agence de la santé et des services sociaux de l’Outaouais
(Outaouais health and social services agency) pays the
difference between the cost invoiced by Ontario and
the amount initially reimbursed by the Régie. A similar
agreement was signed in December 1991 between the
Centre de santé Témiscaming (Témiscaming Health
Centre) and North Bay.
Costs of hospital services 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.
4.3
Coverage During Temporary Absences
Outside Canada
Students, unpaid trainees, Quebec government officials
posted abroad and employees of non profit organizations
working in international aid or cooperation programs
recognized by the Minister of Health and Social Services
must contact the Régie to determine their eligibility. If
the Régie grants them special status, they receive full
reimbursement of hospital costs in case of emergency
or sudden illness, and 75 percent reimbursement in
other cases.
As of September 1, 1996, hospital services provided
outside Canada in case of emergency or sudden illness
are reimbursed by the Régie, usually in Canadian funds,
to a maximum of C$100 per day if the patient was
hospitalized (including in the case of day surgery) or
to a maximum of C$50 per day for out-patient services.
57
Chapter 3: Quebec
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 rendered in a hospital
or hospital centre recognized and accredited by the
appropriate authorities. No reimbursements are made
for nursing homes, spas or similar establishments.
Costs for insured services provided by physicians,
dentists, oral surgeons and optometrists are reimbursed
at the rate that would have been paid by the Régie
to a health professional recognized in Quebec, up to
the amount of the expenses actually incurred. When
they are delivered abroad, all services insured by the
Régime d’assurance maladie are reimbursed at the
Quebec rate, usually in Canadian funds.
An insured person who moves permanently from Quebec
to another country ceases to be a recipient on the day of
departure.
Residents of Quebec who are working or studying abroad
are covered by the plan in effect in that country, when
the stay falls under a social security agreement reached
between the Minister of Health and Social Services and
the country in question.
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.
Quebec hospital institutions had 711,804 admissions for
short stays (including newborns) and 347,654 registrations for day surgeries. These hospitalizations accounted
for 5,037,044 patient days.
Restructuring of the health network: In November 2003,
Quebec announced the implementation of local service
networks across the province. At the heart of each local
network is a new local authority, the Centre de santé
et de services sociaux (CSSS; health and social services
centre). These 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 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 will have to 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.
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, 2011, there were
223 accredited FMGs and 46 network-clinics in Quebec.
5.2
5.0Accessibility
5.1Access 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, 2011, Quebec had 116 institutions operating as hospital centres for a clientele suffering from acute
illnesses. On that date, 20,443 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, 2009, to March 31, 2010,
58
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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: QUEBEC
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 2010–2011
the Régie paid an estimated $5,065.3 million to doctors
in the province, while the amount for medical services
outside the province reached an estimated $12.1 million.
Canada Health Act — Annual Report 2010–2011
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 2010–2011 to institutions
operating as hospital centres for insured health
services provided to residents of Quebec totalled
nearly $10 billion. Payments to hospital centres
outside Quebec for hospital services totalled
approximately $175.64 million.
59
60
Canada Health Act — Annual Report 2010–2011
Chapter 3: Ontario
Ontario
Introduction
Local Health Integration Networks (LHINs) were established under the Local Health System Integration Act,
2006 (LHSIA) to improve Ontarians’ health through
better access to high-quality 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
Languages Services Act to ensure equitable access
to services in French for French-speaking Ontarians.
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
(MOHLTC), Ontario’s health care system was supported
by over $44 billion (including capital) in spending for
2010–2011.
1.2 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.
LHSIA requires each LHIN to prepare an annual report
for the Minister who is required to table the reports in
the Legislative Assembly of Ontario.
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 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 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 in hospitals and health facilities, and by
physicians and other health care practitioners.
Canada Health Act — Annual Report 2010–2011
Reporting Relationship
The Health Insurance Act stipulates that the Minister of
Health and Long-Term Care is responsible for the administration and operation of OHIP, and is Ontario’s public
authority for the purposes of the Canada Health Act.
The Ministry has accountability agreements with each
LHIN that include obligations, measures and targets for
the networks. The agreements also include the funding
allocations for health service providers. LHSIA also provides the LHINs with the authority to fund defined health
service providers and to enter into service accountability
agreements with health service providers.
1.3 Audit of Accounts
Every year the Auditor General of Ontario reports on the
results of his examination of government resources and
administration. The Auditor General’s report is tabled
by the Speaker of the Legislative Assembly, usually in
the fall, at which time it becomes available to the public. Audit reports on select areas of the MOHLTC, which
were 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 6, 2010.
MOHLTC’s accounts and transactions are published
annually in the Public Accounts of Ontario. The
2010–2011 Public Accounts of Ontario was released
on August 23, 2011.
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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; and the 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 subsection 37.1(1) of Regulation 552 and
under 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 2010–2011, 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
of Benefits), and the patient is then entitled to reimbursement by OHIP. However, the number of physicians who
may opt out was fixed (on a “grandparented” basis)
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 25,995 physicians who submitted claims to OHIP in 2010–2011. 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 insured
services are medically necessary and are performed
in a public hospital graded under the Public Hospitals
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 2010–2011
Chapter 3: Ontario
Act as Group A, B, C or D by a dental surgeon who has
been appointed to the dental staff of the public hospital.
• make his or her primary place of residence in
Ontario;
Insured surgical-dental services were provided by
282 dental surgeons in Ontario in 2010-2011.
• subject to some limited exceptions, be physically
present in Ontario for at least 153 days in any
12-month period; and
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 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 transmitting 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
Regulation 552 of the Health Insurance Act specifies
the eligibility criteria for Ontario Health Insurance Plan
(OHIP) coverage.
To be considered a resident of Ontario for the purpose of
obtaining Ontario health insurance coverage generally
speaking, a person must:
• hold Canadian citizenship or an immigration
status as prescribed in Regulation 552 under
the Health Insurance Act;
Canada Health Act — Annual Report 2010–2011
• for most new and returning residents, be physically
present in Ontario for 153 of the first 183 days following the date residence is established in Ontario
(i.e., a person cannot be away from the province
for more than 30 days in the first six months of
residency).
Individuals who are not eligible for OHIP coverage are
those who do not meet the definition of a resident,
including those who do not hold an immigration 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, Canadian
Forces members and ranked Royal Canadian Mounted
Police personnel).
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 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 (HSARB).
MOHLTC is the sole payor for OHIP insured physician,
hospital, and 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 13.1 million Ontario residents were
registered with OHIP and held valid and active health
cards as of March 31, 2011.
3.2 Other Categories of Individual
MOHLTC provides health insurance coverage to
residents of Ontario other than Canadian citizens
and Permanent Residents/Landed Immigrants.
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Chapter 3: Ontario
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
government-wide mandate for the delivery of front-facing
services to the residents of Ontario, which also includes
the issuance of the Ontario Photo Health Card.
Applicants for Permanent Residence: These are persons who have submitted an application for Permanent
Resident status to Citizenship and Immigration Canada
(CIC) and CIC has confirmed that the person meets the
eligibility requirements to apply for permanent residence in Canada and that the application has not yet
been denied.
Protected Persons: These are persons who are determined to be Protected Persons under the terms of
the federal Immigration and Refugee Protection Act.
Members of this group are provided with immediate
Ontario health insurance coverage.
Holders of Temporary Resident Permits/Minister’s
Permits: A Temporary Resident Permit/Minister’s
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/Minister’s 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
64
work in Canada if the person also has a formal agreement in place to work full-time for an employer in
Ontario. The work permit/other document issued by CIC,
or a letter provided by the employer, must set out the
employer’s name, state the person’s occupation with the
employer, and state that the person will be working for
the employer for no less than six consecutive months.
A spouse and/or dependant (under 22 years of age; or
22 years of age or older, if dependent due to a mental or
physical disability) of an eligible foreign member of the
clergy or an eligible foreign worker is also eligible for
Ontario health insurance coverage as long as the spouse
or dependant is legally entitled to stay in Canada.
Live-in Caregivers: Eligible live-in caregivers are persons
who hold a valid Work Permit under the Live-in Caregiver
Program (LCP) administered by the Government of
Canada. The Work Permit for LCP workers does not
have to list the three specific employment conditions
required for all other foreign workers.
Applicants for Canadian Citizenship: These individuals
are eligible for Ontario health insurance coverage if they
have submitted an application for Canadian citizenship
under section 5.1 of the federal Citizenship Act, even if
the application has not yet been approved, provided that
CIC has confirmed that the person meets the eligibility
requirements to apply for citizenship under that section
and the application has not yet been denied.
Migrant Farm Workers: Migrant 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
OHIP-eligible woman who was transferred from
Ontario to receive insured health services that were
pre-approved for payment by OHIP is eligible for
immediate OHIP coverage provided that the mother
was pregnant at the time of departure from Ontario.
3.3 Premiums
No premiums are required to obtain Ontario health
insurance coverage. The Ontario Health Premium is
collected through the provincial income tax system and
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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Ontario
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
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
Canada Health Act — Annual Report 2010–2011
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 MOHLTC with documentation
from their educational institution confirming registration
as a full-time student. Insured family members (spouses
and dependents) of students who are studying in another
province or territory are also eligible for continuous
OHIP eligibility while accompanying students for the
duration of their studies.
In accordance with Regulation 552 of the Health
Insurance Act, most insured residents who want
to travel, work or study outside Ontario, but within
Canada, and maintain OHIP coverage, must have
resided in Ontario for at least 153 days in the last
12-month period immediately prior to departure
from Ontario.
Ontario participates in Reciprocal Hospital Billing
Agreements with all other provinces and territories for
insured in-patient and out-patient hospital services.
Payment is at the agreed upon in-patient rate of the plan
in the province or territory where hospitalization occurs.
Ontario pays the standard out-patient charges set out
by the Interprovincial Health Insurance Agreements
Coordinating Committee. Ontario also participates in
the Physicians’ Reciprocal Billing Agreements with all
other provinces and territories, except Quebec (which
has not signed a reciprocal agreement with any other
province or territory), for insured physician services.
Ontario residents who may be required to pay for
physician services received in Quebec can submit their
receipts to MOHLTC for payment as an insured service
at Ontario rates.
4.3 Coverage During Temporary Absences
Outside Canada
Health insurance coverage for insured Ontario residents
during extended absences (longer than 212 days) outside
Canada is governed by sections 1.7 through 1.14 of
Regulation 552 of the Health Insurance Act.
The Ministry requests that residents apply to MOHLTC
to confirm this coverage before their departure and provide documents explaining the reason for their absence
65
Chapter 3: Ontario
outside Canada. 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.
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.
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:
4.4 Reason
OHIP Coverage
Study
Duration of a full time academic studies (unlimited).
Work
Five year terms (provided specific residency
requirements are met for 2 years between each
term).
Charitable Worker
Five year terms (provided specific residency
requirements are met for 2 years between each
term).
Vacation/Other
Two year terms (provided specific residency
requirements are also met for 5 years between
each term).
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.
Generally speaking, the prior approval application must
establish that the services or tests are:
• medically necessary;
Certain family members may also qualify for continuous
Ontario health insurance coverage while accompanying
the primary applicant on an extended absence outside
Canada.
• 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;
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.
• generally accepted by the medical profession in
Ontario as appropriate for a person in the same
circumstances as the insured person;
Out-of-country emergency hospital costs are reimbursed
at Ontario fixed per diem rates of:
• not experimental;
• a maximum $400 (CAD) for in-patient services;
• 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 2010–2011, 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
66
• 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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Ontario
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 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.
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 Number/Card Validation
to aid health care providers and patients with access to
the information requested for OHIP and claims payment.
Providers may subscribe for validation privileges to
verify patient eligibility and health number/version code
status (card status). If patients require access to insured
services and do not have a health card in their possession, the provider may obtain the necessary information
by submitting to the Ministry a Health Number Release
Form signed by the patient. An accelerated process
for providers to obtain patient health numbers is also
provided by ServiceOntario 24 hours a day, seven days
a week through the Health Number Look Up service.
Public hospitals in Ontario are not permitted to refuse
the admission of a patient if by refusal of admission the
patient’s life would be endangered.
Acute care priority services are designated highly
specialized hospital-based services that deal with
life-threatening conditions such as organ transplants,
cancer surgery and treatments and neuro services.
These services are often high-cost and are rapidly
growing, which has made access a concern. Generally,
Canada Health Act — Annual Report 2010–2011
these services are managed provincially, on a timelimited basis. Acute care priority services include:
• selected cardiovascular services;
• selected cancer services;
• chronic kidney disease;
• critical care services; and
• organ and tissue donation and organ
transplantation.
Primary Health Care: During 2010–2011, Ontario continued to align its new and existing primary health care
delivery models to help improve and expand access to
primary health care physician services for all Ontarians.
The various primary health care physician compensation models encourage access to comprehensive primary
health care services for Ontario as a whole, as well as for
targeted population groups and remote under-serviced
communities.
Health Care Connect (HCC): HCC helps Ontarians who
are without a family health care provider (family doctor
or nurse practitioner) to find one. 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 2010–2011, MOHLTC continued to administer
various initiatives in order to improve access to health
care services across the province. Ontario is increasing physician supply, and enhancing the retention
and distribution of physicians in the province by such
measures as:
• increasing 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 new Northern Ontario School for
Medicine (NOSM); and
• supporting training and assessment programs
for International Medical Graduates (IMGs)
and other qualified physicians who do not meet
certain requirements for practice in Ontario.
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.
67
Chapter 3: Ontario
• HealthForceOntario Northern and Rural
Recruitment and Retention (NRRR) Initiative:
The The NRRR (launched April 2010) supports
the recruitment and retention of physicians in
rural and northern communities. The NRRR
initiative provides grants to physicians and new
physician graduates to set up new practices in
a northern or highly rural community with a
Rurality Index for Ontario (RIO) 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).
• Northern Health Travel Grant (NHTG) Program:
The NHTG 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 also promotes using specialist services
located in northern Ontario, which encourages
more specialists to practice and remain in the north.
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 2010–2011, 98% of General Practitioners received
fee-for-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 Care
(CHC), Rural and Northern Physician Group Agreement
(RNPGA), Group Health Centre (GHC), Blended Salary
Model (BSM), and specialized agreements and Family
Health Teams (FHTs) build upon existing primary
health care physician funded models by providing
funding for inter-disciplinary team 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
68
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). A four year Physician Services
Agreement, from April 2008 to March 31, 2012, was
reached in October 2008. The 2008 Physician Services
Agreement centers on delivering on two key government
priorities—access to family health care and reducing
congestion in emergency departments. The Agreement
provides for a 3% one time payment to physicians in the
first year of the Agreement and increases to the Schedule
of Benefits, with 5% in the second year, 3% in the third
year and 4.25% in the fourth year. Investments in the
Schedule of Benefits are not across-the-board but are
implemented to address Ministry priorities and provide
income relativity between OMA sections.
The Agreement also includes investments in recruitment and retention initiatives and in northern/rural
programs to support stabilizing physician human
resources as well as investments in other Ministry
priority areas, such as mental health, diagnostic
services and care of the elderly. Additionally, through
the Agreement, $100 million in performance based
funding is provided for a new Local Health Integration
Network (LHIN)-Physician Collaboration Incentive
Fund. The fund recognizes and rewards the local
efforts of physician groups who work together and
in collaboration with other service providers to support the needs of patients in four key areas: Most
Responsible Physician, Emergency Department,
Unattached Patients, and Hospital On-Call Coverage.
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
The Ontario budget system is a prospective reimburse­
ment 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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Ontario
With the Excellent Care for All Act (ECFA), Ontario
will be moving to a patient-based payment system
for funding hospitals. Patient-based payment (PbP) is
an activity-based funding approach that reimburses
providers for the types and quantities of patients they
treat, using evidence-informed rates that are adjusted
for patient complexity and quality of care delivered.
PbP 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. PbP is a significant shift from the way Ontario
hospitals are currently funded, still largely based on
historically derived global budgets established in 1969.
The implementation of patient-based payment will be an
enabler for health system transformation and aims to be
responsive to the needs of patients and populations, be an
incentive to improving quality, efficiency and integration,
and support the system transformation agenda of ECFA.
ECFA and PbP implementation will combine activitybased funding with a component of fixed budgeting to
create a system that promotes access, quality and efficiency, establishes payment levers to advance policy and
system objectives, while still ensuring overall cost containment. PbP implementation is a critical structural reform
for reducing health spending growth from current 6%–7%
annual increases to 3.1% by 2012–2013.
Person-centred, patient-based payment funding
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. 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 and
provide funding that reflects the quality of care that
providers deliver and promote evidence-based practice.
When they assumed responsibility for their local health
care systems, LHINs negotiated two-year Hospital
Service Accountability Agreements (HSAAs) with the
hospitals and are the lead for the Hospital Annual
Planning Submissions, which are the precursors to the
HSAAs. Payments to hospitals have traditionally been
based on historical global allocations and multiyear
incremental increases that incorporate population
growth and anticipated service demands within the
available provincial budget.
Public hospitals submit planning submissions to the
LHINs that are the result of broad consultations within
Canada Health Act — Annual Report 2010–2011
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 HSAA.
The HSAA 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, total
margin); 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.
All the indicators have a performance standard and target that are designed to incentivise 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 presenting a risk, the hospital and LHIN
develop a Performance Improvement Plan to get the
hospital back on track to achieving its targets.
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.
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 2010-2011 publications.
69
Chapter 3: Ontario
Registered Persons
2006–2007
1.Number as of March 31st (#).
12,600,000
2007–2008
2
12,700,000
2008–2009
2
12,800,000
2009–2010
12,900,000
2
2010–2011
13,100,000
2
2
Insured Hospital Services Within Own Province or Territory
Public Facilities
2006–2007
2.Number (#).
3.Payments for insured health services ($).
Private For-Profit Facilities
2007–2008
2008–2009
2009–2010
2010–2011
150
3
150
3
149
3
149
3
149
3
13,000,000,000
4
13,600,000,000
4
14,200,000,000
4
14,800,000,000
4
15,527,899,500
4
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
4.Number of private for-profit facilities
providing insured health services (#).
not available
5
not available
5
not available
5
not available
5
not available
5
5.Payments to private for-profit facilities
for insured health services ($).
not available
5
not available
5
not available
5
not available
5
not available
5
Insured Hospital Services Provided to residents in another province or territory
6.Total number of claims, in-patient (#).
7.Total payments, in-patient ($).
8.Total number of claims, out-patient (#).
9.Total payments, out-patient ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
8,037
7,130
9,457
8,185
8,231
49,870,000
45,712,000
65,183,888
64,688,077
68,384,505
139,036
166,373
161,193
138,594
130,855
25,576,000
31,052,000
38,030,901
36,399,952
35,431,819
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11.Total payments, in-patient ($).
20,800
24,327
21,869
28,223
28,420
76,828,432
113,663,332
136,036,532
91,456,638
52,706,316
12.Total number of claims, out-patient (#).
not available
13.Total payments, out-patient ($).
not available
6
not available
not available
6
not available
not available
6
not available
not available
6
not available
6
not available
2. These estimates represent the number of Valid and Active Health Cards (have current eligibility and resident has incurred a claims in the last 7 years).
3. “Number represents all publicly funded hospitals excluding specialty psychiatric hospitals. Specialty psychiatric hospitals are excluded in order to conform to the 2009–2010
Canada Health Act Annual Report reporting guide.
4. Amount represents funding for all public hospitals excluding specialty psychiatric hospitals.
5. Data are not collected in a single system in MOHLTC. Further, the MOHLTC is unable to categorize providers/facilities as “for-profit” as MOHLTC does not have financial
statements detailing service providers’ disbursement of revenues from the Ministry.
6.
Included in #10.
70
Canada Health Act — Annual Report 2010–2011
Chapter 3: Ontario
Insured Physician Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
23,201
23,859
24,411
25,166
25,995
49
40
39
35
34
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of non-participating physicians (#).
0
7
0
7
0
7
0
7
0
7
17.Total payments for services provided
by physicians paid through all payment
methods ($).
7,791,581,966
8
8,410,478,000
8
9,324,794,000
8
10,033,761,000
8
9,070,713,617
8
18.Total payments for services provided by
physicians paid through fee-for-service ($).
5,642,049,000
5,962,775,787
6,528,353,572
6,812,333,798
7,052,261,365
Insured Physician Services Provided to Residents in Another Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
627,375
759,570
683,377
596,430
723,766
23,754,500
25,180,900
26,471,536
26,204,597
25,237,480
19.Number of services (#).
20.Total payments ($).
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
182,693
211,323
247,741
216,715
213,717
19,351,944
37,901,297
54,780,594
41,652,064
12,455,597
Insured Surgical-Dental Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
316
317
291
277
282
92,264
91,540
99,212
99,427
96,797
14,229,896
13,423,384
13,916,464
14,324,505
13,525,890
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
7. Ontario has no non-participating physicians, only opted-out physicians who are reported under item #15.
8. Total Payments includes payments made to Ontario physicians through Fee-for-Service, Primary Care, Alternate Payment Programs, 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.
Canada Health Act — Annual Report 2010–2011
71
72
Canada Health Act — Annual Report 2010–2011
Chapter 3: MANITOBA
• Implementation of IMPRxOVE (Improving
Medication Prescribing and Outcomes via
Medical Education) Program, a first-in-Canada
initiative, that is expected to improve the safety
and health outcomes for Manitobans receiving
mental health medications.
• Launch of an online drug formulary which provides health care professionals and the public with
current information on drug benefits available
through the Pharmacare program.
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 in such areas of mental
health, diagnostics/laboratory, public health
inspection and provincial nursing stations.
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 2010–2011 included:
• Commencement of a revision of strategic priorities and goals established for the Department in
September 2010 to set expectations for future
accountability. New departmental processes and
tools to support this planning were initiated in
early 2011.
• Implementation of the Performance Indicator
Project to address the regional health authorities’
needs for technology to support the collection,
storage, reporting, measurement and monitoring
of key performance indicators, as well as enabling
regional health authorities to track and report on
performance indicators that have been identified
as shared priorities across regions.
• Launch of eChart Manitoba, the province’s
electronic health-record system. This included
implementation of electronic medical records
program processes, procedures and technology
to enable timely data feeds from Manitoba Health
Pharmacare and immunization data to the provincial eChart program hosted at Manitoba eHealth.
Canada Health Act — Annual Report 2010–2011
• Funding and support of the first-in-Canada organ
donation physician specialist team to increase
organ transplants and access to life saving organ
donations.
• Commencement of initiatives towards the Family
Doctor for Every Manitoban by 2015 initiative.
This initiative supports the nurse practitioner
quick-care clinics and mobile clinics while expanding the successful Advanced Access care model in
the province.
• Continued support for the improvement to doctor
education, recruitment and retention strategies by
supporting medical enrolment and keeping medical school tuitions affordable.
• Improvements to the doctor education, recruitment and retention strategy in Manitoba that has
resulted in a net increase of 405 new doctors in
2010.
• Continued aggressive recruitment and retention
of nurses in 2010, resulting in a net gain of
3,026 nurses since 1999.
• Implemented the Master of Psychiatric Nursing
program at Brandon University, the first one in
Canada, which started in January 2011.
1.0 Public Administration
1.1Health Care Insurance Plan and
Public Authority
The Manitoba Health Services Insurance Plan (MHSIP)
is administered by the Department of Health under the
Health Services Insurance Act, R.S.M. 1987, c. H35.
The MHSIP is administered under this Act for insurance
in respect of the costs of hospital, personal care, and
medical and other health services referred to in acts of
the Legislature or regulations thereunder.
The Minister of Health is responsible for administering
and operating the Plan. The Minister may also enter
73
Chapter 3: MANITOBA
into contracts and agreements with any person or group
that he or she considers necessary for the purposes of
the Act.
The Minister may also make grants to any person
or group for the purposes of the Act on such terms
and conditions that are considered advisable. Also,
the Minister may, in writing, delegate to any person
any power, authority, duty or function conferred or
imposed upon the Minister under the Act or under
the regulations.
There were no legislative amendments to the Act or the
regulations in the 2010–2011 fiscal year that affected the
public administration of the Plan.
1.2
Reporting Relationship
Section 6 of the Health Services Insurance Act requires
the Minister to have audited financial statements of the
Plan showing separately the expenditures for hospital
services, medical services and other health services. The
Minister is required to prepare an annual report, which
must include the audited financial statements, and to
table the report before the Legislative Assembly within
15 days of receiving it, if the Assembly is in session. If
the Assembly is not in session, the report must be tabled
within 15 days of the beginning of the next session.
1.3Audit 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 2010–2011 fiscal
year and is contained in the Manitoba Health and
Healthy Living Annual Report, 2010–2011. It is available at http://www.gov.mb.ca/health/ann/index.html.
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.
2.2Insured 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 practise medicine in Manitoba,
and be registered and licensed under the Medical Act.
As of March 31, 2011, there were 2,528 registered
physicians 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.
Sections 46 and 47 of Health Services Insurance
Act, as well as the Hospital Services Insurance and
Administration Regulation (M.R. 48/93), provide for
insured hospital services.
Before rendering a medical service to an insured person, physicians must give the patient reasonable notice
that they propose to collect any fee for the medical service from them or any other person except the Minister.
The physician is responsible for submitting a claim to
the Minister on the patient’s behalf and cannot collect
fees in excess of the benefits payable for the service
under the Act or regulations. To date, no physicians
have opted out of the medical plan in Manitoba.
As of March 31, 2011, there were 96 facilities providing
insured hospital services to both in- and out-patients.
The range of physician services insured by Manitoba
Health is listed in the Payment for Insured Medical
2.0Comprehensiveness
2.1Insured Hospital Services
74
Canada Health Act — Annual Report 2010–2011
Chapter 3: MANITOBA
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 2010–2011, 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 physician’s 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.
2.3Insured 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 as of March 31, 2011.
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
will negotiate the fee with Manitoba Health.
2.4
Uninsured Hospital, Physician and
Surgical-Dental Services
The Excluded Services Regulation (M.R. 46/93) made
under the Health Services Insurance Act sets out
those services that are not insured. These include:
examinations and reports for reasons of employment, insurance, attendance at university or camp,
or performed at the request of third parties; group
Canada Health Act — Annual Report 2010–2011
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 2010–2011.
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
75
Chapter 3: MANITOBA
missionaries, individuals with out-of-country employment and individuals undertaking sabbatical leave to be
outside Manitoba for up to two years while still remaining residents of Manitoba. Students are deemed to be
Manitoba residents while in full-time attendance at an
accredited educational institution. Section 8(1) extends
residency to individuals who are legally entitled to work
in Manitoba and have a work permit of 12 months
or more.
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 the following federal
statutes: Aeronautics Act; Civilian War-related Benefits
Act; Government Employees Compensation Act; Merchant
Seaman Compensation Act; National Defence Act; Pension
Act; Royal Canadian Mounted Police Act; Veteran’s
Rehabilitation Act; or under legislation of any other
jurisdiction (Excluded Services Regulations subsection
2(2)). The excluded are residents who are members of
the Canadian Forces and the Royal Canadian Mounted
Police (RCMP), and federal inmates. These residents
become eligible for Manitoba Health coverage upon
discharge from the Canadian Forces, the RCMP, or
if an inmate of a penitentiary 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 consecutive months. 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
76
(PHIN) is used for payment of all hospital services and
for the provincial drug program.
As of March 31, 2011, there were 1,246,420 residents
registered with the health care insurance plan.
There is no provision for a resident to opt out of the
Manitoba Health Plan.
3.2Other 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, and be legally entitled to be
in Canada before receiving Manitoba Health coverage.
As of March 31, 2011, there were 5,511 individuals on
work 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 Act (Canada).
No legislative amendments to the Act or the regulations
in the 2010–2011 fiscal year affected universality.
4.0Portability
4.1Minimum 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 fulltime enrolment at any accredited educational institution.
The additional requirement is that they intend to return
and reside in Manitoba after completing their studies.
Manitoba has formal agreements with all Canadian provinces and territories for the reciprocal billing of insured
hospital services. Manitoba has a bilateral agreement
with the Province of Saskatchewan for Saskatchewan residents who receive care in Manitoba border communities.
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Chapter 3: MANITOBA
In-patient costs are paid at standard rates approved by
the host province or territory. Payments for in-patient,
high-cost procedures and out-patient services are based
on national rates agreed to by provincial and territorial health plans. These include all medically necessary
services as well as costs for emergency care.
Except for Quebec, medical services incurred in all
provinces or territories are paid through a reciprocal
billing agreement at host province or territory rates.
Claims for medical services received in Quebec are
submitted by the patient or physician to Manitoba
Health for payment at host province rates.
4.3
Coverage During Temporary Absences
Outside Canada
The Residency and Registration Regulation (M.R. 54/93,
sub-section 7(1)) defines the rules for portability of health
insurance during temporary absences from Canada.
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 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 Admini­
stration 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
Canada Health Act — Annual Report 2010–2011
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.
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. Physician services received
in the United States are paid at the equivalent Manitoba
rate for similar services. 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 and
payment is less than 100 percent of the amount billed
for insured services, Manitoba Health will consider
additional funding based on financial need.
4.4
Prior Approval Requirement
Prior approval by Manitoba Health is not required for
services provided in other provinces or territories or
for emergency care provided outside Canada. Prior
approval is required for elective hospital and medical
care provided outside Canada. An appropriate medical specialist must apply to Manitoba Health to receive
approval for coverage.
No legislative amendments to the Act or the regulations in the 2010–2011 fiscal year had an effect on
portability.
5.0Accessibility
5.1Access 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
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Chapter 3: MANITOBA
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), 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
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 co-ordinated over 30 primary and
specialty clinics to successfully complete the Advanced
Access training, enabling them to offer patients sameday access to a primary care provider and five-day
access to a specialist.
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, outpatients and day surgeries, which are also insured services.
The Western Manitoba Cancer Centre (WMCC) located
at the Brandon Regional Health Centre (BRHC) is the
first location outside of Winnipeg to provide radiation
therapy. This $24 million facility with a linear accelerator
is home to a broad range of cancer treatment including
chemotherapy and support services. It is expected that
the WMCC will reduce wait times for radiation treatment.
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
78
drug formulary, acquisition of new equipment, and by
staff recruitment and retention initiatives.
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 2010–2011, 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. It is the standard means of
requesting and booking operating room cases, and
capturing wait time information for over 190 WRHA
surgeons. More than 85% of surgical services in
Manitoba are provided in the WRHA. The wait time
data collection functions of the tool have also been
implemented in various medical and allied health
programs to capture access information.
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.
The MBTelehealth program continues to grow and
currently has over 100 sites in Manitoba, including
24 sites in First Nation communities. Approximately
70% of usage is for the delivery of clinical services;
9327 of a total of 12,817 events. Other uses include
continuing education for health care staff, administrative meetings and tele-visitation. Provider and patient
response to the program continues to be very positive
and demand for new sites continues to be high.
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 17,118 active
practicing nurses in Manitoba in 2010. This is a net
gain of 494 more nurses than in 2009. 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 Winnipeg
Regional Health Authority’s strategy, the Winnipeg Critical
Care Nursing Education Program (WCNEO), was aimed
Canada Health Act — Annual Report 2010–2011
Chapter 3: MANITOBA
at increasing the number of intensive care nurses in
the province, thus reducing nursing overtime costs, and
decreasing surgery cancellations and bed closures.
The NRRF also contributes significantly to improving the nursing supply in Manitoba through initiatives
such as relocation assistance, the Conditional Grant
Program to encourage 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 101 as of the December 31, 2010 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 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.
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 the Medical Review
Committee. 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.
Manitoba Health continued to support initiatives to
improve access to physicians in rural and northern
areas of the province.
Manitoba continues to experience increases in the
number of new physicians registering with the licensing
body. Manitoba has introduced greater funding flexibility to the return of service for students (for example,
Canada Health Act — Annual Report 2010–2011
fourth year grants of $25,000 in return for service in
a community designated by the province) by allowing
return by locum (maximum 3 months per year over
4 years). The province also provides a provincial specialist fund to specialists recruited to Manitoba, in the
amount of $15,000. In order to incent more Manitoba
graduates to practice in Manitoba, the eligibility requirements for this fund have been broadened to allow
recipients of funding through the Medical Student/
Resident Financial Assistance Program (MSRFAP) to
receive funding through the specialist fund as well.
Recent announcements that further support physicians
include the Physician Resettlement Fund and changes to
the MSRFAP program. 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. The
MSRFAP was re-launched to provide eligible medical
undergraduates $12,000 in funding in each of their four
years of medical school. Each grant requires a commitment to return six months of service to under-serviced
populations upon graduation. The new program will
be available to medical students beginning in the fall of
2011. Since 2001, Manitoba has supported an expansion
in medical school class sizes. In 2008, the Province, in
partnership with the Federal Government introduced
the Northern/Remote Family Medicine Residency Stream
(formerly known as the Northern Remote Physician
Practice Initiative). The initiative is a two-year family
medicine residency training stream-specific to the
rural/north, after which applicants must return service
of 2+ years in rural/remote Manitoba, and upon completion of return of service are guaranteed consideration for
a specialty residency position in 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,
foreign-trained physicians can achieve conditional
licensure to practice medicine in return for agreeing to
work in a sponsoring rural regional health authority.
Eligible applicants for the Medical Licensure Program for
International Medical Graduates may enter one year of
residency training similar to family medicine residency
training and upon successful completion of that training
may be granted conditional licensure for primary care
practice in a rural or northern community of Manitoba.
Eligible applicants for the family practice assessment
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Chapter 3: MANITOBA
process leading to licensure will complete an orientation,
a three day Family Practice Assessment, and a three
month Clinical Field Assessment. 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 Non-Registered Specialist
Assessment Program initiative assists in facilitating the
assessment of physicians whose practice will be limited
to a specialty field of training. Through this program,
clinical assessments are organized and facilitated in
order for foreign-trained physicians to meet the College
of Physicians and Surgeons of Manitoba (CPSM) criteria
for conditional licensure. The province has been working
with stakeholders to improve the transparency and consistency of licensure processes related to foreign-trained
physicians. There is now an integrated process through
the University of Manitoba, Faculty of Medicine, for
screening and assessing candidates. The improvements
will ensure that the strongest candidates are identified
and supported to transition successfully to practice
in Manitoba. The PRCO has also concluded amendments to the Non-Registered Specialist Assessment
Program (NRSAP), which will streamline the process
for applicants.
5.2
Physician Compensation
Manitoba continues to employ the following methods
of payment for physicians: fee-for-service, contract,
blended and sessional.
The Health Services Insurance Act governs remuneration to physicians for insured services. There were
no amendments to the Health Services Insurance Act
related to physician compensation during the 2010–2011
fiscal year.
Fee-for-service remains the dominant method of payment for physician services. Notwithstanding, alternate
payment arrangements constitute a significant portion
of the total compensation to physicians in Manitoba.
Alternate-funded physicians are those who receive non
fee-for-service compensation, including through a salary (employment relationship) or those who work on an
independent contract basis. Manitoba also uses blended
payment methods to adjust fee-for-service income that
may not be adequate to compensate for all services rendered by the physician. As well, physicians may receive
sessional payments for providing medical services on a
time based arrangement, as well as stipends for on-call
and other responsibilities.
80
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, 2008 to
March 31, 2011.
5.3
Payments to Hospitals
Division 3.1 of Part 4 of the Regional Health Authorities
Act sets out the requirements for operational agreements
between regional health authorities and the operators of
hospitals and personal care homes, defined as “health
corporations” under the Act.
Pursuant to the provisions of this division, regional
health authorities are prohibited from providing funding to a health corporation for operational purposes
unless the parties have entered into a written agreement for this purpose that enables the health services
to be provided by the health corporation, the funding
to be provided by the regional health authority for the
health services, the term of the agreement, and a dispute resolution process and remedies for breaches. If
the parties cannot reach an agreement, the Act enables
them to request that the Minister of Health appoint a
mediator to help them resolve outstanding issues. If the
mediation is unsuccessful, the Minister is empowered to
resolve the matter or matters in dispute. The Minister’s
resolution is binding on the parties.
There are three regional health authorities which
have hospitals operated by health corporations in
their health regions. The regional health authorities
have concluded the required agreements with health
corporations. The operating agreements enable the
regional health authority to determine funding based on
objective evidence, best practices and criteria that are
commonly applied to comparable facilities. In all other
regions, the hospitals are operated by the Regional
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
Canada Health Act — Annual Report 2010–2011
Chapter 3: MANITOBA
Act. Section 23 of the Act requires that authorities allocate their resources in accordance with the approved
regional health plan.
6.0 Recognition Given to
Federal Transfers
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.
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 who are implementing programs
using this funding.
No legislative amendments to the Act or the regulations
in 2010–2011 had an effect on payments to hospitals.
Canada Health Act — Annual Report 2010–2011
81
Chapter 3: MANITOBA
Registered Persons
2006–2007
1.Number as of March 31st (#).
1,178,457
2007–2008
1
1,186,386
2008–2009
1
1,209,401
2009–2010
1,228,246
1
2010–2011
1
1,230,270
1
Insured Hospital Services Within Own Province or Territory
Public Facilities
2.Number (#).
3.Payments for insured health services ($).
Private For-Profit Facilities
4.Number of private for-profit facilities
providing insured health services (#).
5.Payments to private for-profit facilities
for insured health services ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
97
97
97
96
96
not available
not available
not available
not available
not available
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
1
1
1
1
1
1,292,830
1,289,964
1,553,438
1,570,832
1,541,540
Insured Hospital Services Provided to residents in another province or territory
6.Total number of claims, in-patient (#).
7.Total payments, in-patient ($).
8.Total number of claims, out-patient (#).
9.Total payments, out-patient ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
2,806
2,823
3,280
2,626
2,844
19,431,036
18,731,739
24,489,298
21,612,535
27,092,558
30,357
31,329
35,957
28,729
30,983
6,306,240
6,933,920
9,662,718
8,655,118
10,454,203
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11.Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
589
549
658
552
634
1,294,963
1,791,864
3,252,651
1,924,044
2,454,364
7,673
8,796
10,121
10,097
10,706
1,695,844
2,692,096
2,650,500
2,954,321
3,022,630
1. The population data is based on records of residents registered with Manitoba Health as of June 1.
82
Canada Health Act — Annual Report 2010–2011
Chapter 3: MANITOBA
Insured Physician Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
1,968
2,050
2,073
2,121
2,276
15.Number of opted-out physicians (#).
not applicable
0
0
0
0
16.Number of non-participating physicians (#).
not applicable
not applicable
not applicable
not applicable
not applicable
17.Total payments for services provided
by physicians paid through all payment
methods ($).
700,465,401
721,552,291
789,101,000
843,087,000
920,890,000
18.Total payments for services provided by
physicians paid through fee-for-service ($).
438,813,332
459,573,573
476,227,782
552,890,200
553,924,806
14.Number of participating physicians (#).
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
248,900
290,775
243,881
237,192
267,122
9,997,409
9,985,987
9,721,570
10,287,990
9,909,927
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
6,486
6,414
7,446
6,768
7,226
541,403
701,829
725,382
627,563
953,272
Insured Surgical-Dental Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
122
120
131
135
133
4,205
4,616
4,833
5,950
5,475
984,621
1,107,357
1,175,314
1,701,655
1,522,545
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
Canada Health Act — Annual Report 2010–2011
83
84
Canada Health Act — Annual Report 2010–2011
Chapter 3: Saskatchewan
(a component of the Strategy and Innovation Branch)
report directly to the Deputy Minister.
The re-organization was designed to strengthen the
Ministry’s customer/client-focus; increase opportunities
for innovation and collaboration; and, through these,
transform the health care experience to make it more
patient- and family-focused.
For more information about the Ministry’s programs and
services, please visit the Ministry of Health website at:
Saskatchewan
Introduction
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.
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 38,000 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.
In 2010–2011, the Ministry was re-organized into:
Specialized Programs; Community and Primary Health;
and Strategy and Performance Management. The
Saskatchewan Surgical Initiative; Communications
Branch; and Quality and Process Improvement
Canada Health Act — Annual Report 2010–2011
www.health.gov.sk.ca
1.0 Public Administration
1.1Health Care Insurance Plan and
Public Authority
The provincial government is responsible for funding
and ensuring the provision of insured hospital, physician and surgical-dental services in Saskatchewan.
Section 6.1 of the Department of Health Act authorizes
that the Minister of Health may:
• pay part of, or the whole of, the cost of providing health services for any persons or classes of
person who may be designated by the Lieutenant
Governor-in-Council;
• make grants or loans, or provide subsidies to
regional health authorities, health care organizations or municipalities for providing and operating
health services or public health services;
• pay part of, or the whole of, the cost of providing
health services in any health region or part of a
health region in which those services are considered
by the Minister to be required;
• make grants or provide subsidies to any health
agency that the Minister considers necessary; and
• make grants or provide subsidies to stimulate and
develop public health research, and to conduct
surveys and studies in the area of public health.
Sections 8 and 9 of the Saskatchewan Medical Care
Insurance Act provide the authority for the Minister of
Health to establish and administer a plan of medical care
insurance for residents. The Regional Health Services
Act 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.
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Chapter 3: Saskatchewan
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.
Foundation shall be audited at least once a year by the
Provincial Auditor or by a designated representative.
1.2
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.
Reporting Relationship
The Ministry of Health is directly accountable, and
regularly reports, to the Minister of Health on the
funding and administering the funds for insured
physician, surgical-dental and hospital services.
Section 36 of the Saskatchewan Medical Care Insurance
Act prescribes that the Minister of Health submit an
annual report concerning the medical care insurance
plan to the Legislative Assembly.
The Regional Health Services Act prescribes that each
regional health authority shall submit to the Minister
of Health:
• a report on the activities of the regional health
authority; and
• a detailed, audited set of financial statements.
Section 54 of the Regional Health Services Act requires
that regional health authorities and the Cancer Agency
shall submit to the Minister any reports that the Minister
may request from time to time. Regional health authorities and the Cancer Agency are required to submit a
financial and health service plan to the Saskatchewan
Ministry of Health.
1.3Audit 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
86
The most recent audits were for the year ended
March 31, 2011.
The Office of the Provincial Auditor for Saskatchewan
also prepares reports to the Legislative Assembly of
Saskatchewan. These reports are designed to assist
the government in managing public resources and to
improve the information provided to the Legislative
Assembly. They are available on the Provincial
Auditor’s website at:
http://www.auditor.sk.ca
2.0Comprehensiveness
2.1Insured Hospital Services
Section 8 of the Regional Health Services Act (the Act)
gives the Minister the authority to provide funding to a
regional health authority or a health care organization
for the purpose of the Act.
Section 10 of the Regional Health Services Act permits
the Minister to designate facilities including hospitals,
special care homes and health centres. Section 11 allows
the Minister to prescribe standards for delivering services
in those facilities by regional health authorities and health
care organizations that have entered into service agreements with a regional health authority.
The Act sets out the accountability requirements for
regional health authorities and health care organizations.
These requirements include submitting annual operational, financial and health service plans for ministerial
approval (sections 50–51); establishing community advisory networks (section 28); and reporting critical incidents
(section 58). The Minister also has the authority to establish a provincial surgical registry to help manage surgical
wait times (section 12). The Minister retains authority to
inquire into matters (section 59); appoint a public administrator if necessary (section 60); and approve general and
staff practitioner by-laws (sections 42–44).
Funding for hospitals is included in the funding provided
to regional health authorities.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Saskatchewan
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.
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.
2.2Insured 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
Canada Health Act — Annual Report 2010–2011
As of March 31, 2011, there were 1,946 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, 2011, 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
(modernization) with significant monetary impact. The
Executive Director of the Medical Services Branch manages this process. When the Medical Services Plan covers
a new insured physician service or significant revisions
occur to the Physician Payment Schedule, 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.
2.3Insured Surgical-Dental Services
Dentists may opt out or not participate in the Medical
Services Plan, but if doing so, they must opt out of all
insured surgical-dental services. The dentist must also
advise beneficiaries that the surgical-dental services to
be provided are not insured and that the beneficiary
is not entitled to reimbursement for those services.
Written acknowledgement from the beneficiary indicating that he or she understands the advice given by
the dentist is also required. There were no opted-out
dentists in Saskatchewan as of March 31, 2011.
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
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Chapter 3: Saskatchewan
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 proper 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 Plan.
2.4
Uninsured Hospital, Physician and
Surgical-Dental Services
Uninsured hospital, physician and surgical-dental
services in Saskatchewan include: in-patient and outpatient 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 bone mineral densitometry provided outside Saskatchewan without prior
written approval; non-emergency insured hospital,
physician or surgical-dental services obtained outside
Canada without prior written approval; non-medically
required elective physician services; surgical-dental
services that are not medically necessary; and services
received under other public programs including the
Workers’ Compensation Act, the federal Department of
Veteran Affairs and the Mental Health Services Act.
As a matter of policy and principle, insured hospital,
physician and surgical-dental services are provided
to residents on the basis of assessed clinical need.
Compliance is periodically monitored through consultation with regional health authorities, physicians and
dentists. There are no charges allowed in Saskatchewan
for medically necessary hospital, physician or surgicaldental 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.
88
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.
The Ministry of Health implemented a new policy on the
coverage of chiropractic services effective April 1, 2010.
Universal chiropractic coverage was de-insured and lowincome individuals receiving Supplementary or Family
Health benefits, or on the Seniors Income Plan, became
eligible for a maximum 12 treatments per year. Previous
to this policy change, chiropractic services for the general public were insured on a co-payment basis and low
income residents received full coverage.
3.0Universality
3.1Eligibility
The Saskatchewan Medical Care Insurance Act (sections
2 and 12) and the Medical Care Insurance Beneficiary
and Administration Regulations define eligibility for
insured health services in Saskatchewan. Section 11 of
the Act requires that all residents register for provincial
health coverage.
Eligibility is limited to residents. A “resident” means
a person who is legally entitled to remain in Canada,
who makes his or her home and is ordinarily present in Saskatchewan, or any other person declared by
the Lieutenant Governor-in-Council to be a resident.
Canadian citizens and permanent residents of Canada
relocating from within Canada to Saskatchewan are
generally eligible for coverage on the first day of the
third month following establishment of residency in
Saskatchewan.
Canada Health Act — Annual Report 2010–2011
Chapter 3: 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 province; and
• persons eligible for coverage from their home
province or territory for the period of their stay
in Saskatchewan (e.g., students and workers
covered under temporary absence provisions
from their home province or territory).
Such people become eligible for coverage as follows:
• discharged members of the Canadian Forces
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, 2010, was 1,070,477.
3.2Other Categories of Individual
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.
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, 2010, there were 9,552 such temporary
residents registered with the Saskatchewan Ministry
of Health.
Canada Health Act — Annual Report 2010–2011
4.0Portability
4.1Minimum Waiting Period
In general, insured persons from another province or
territory who move to Saskatchewan are eligible on
the first day of the third month following establishment
of residency. However, where one spouse arrives in
advance of the other, the eligibility for the later arriving
spouse is established on the earlier of a) the first day of
the third month following arrival of the second spouse;
or b) the first day of the thirteenth month following the
establishment of residency by the first spouse.
4.2
Coverage During Temporary Absences
in Canada
Section 3 of the Medical Care Insurance Beneficiary
and Administration Regulations of the Saskatchewan
Medical Care Insurance Act prescribes the portability
of health insurance provided to Saskatchewan residents
while temporarily absent within Canada. There were
no changes to the in-Canada temporary absence provisions in 2010–2011.
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
is required); • employment of up to 12 months (no documentation
required); and
• vacation and travel of up to 12 months.
Saskatchewan has bilateral reciprocal billing agreements
with all provinces for hospital services, and all but Quebec
for physician services. Rates paid are at the host province
rates. The reciprocal arrangement for physician services
applies to every province except Quebec.
Payments/reimbursement to Quebec physicians, for
services to Saskatchewan residents, are made at
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Chapter 3: Saskatchewan
Saskatchewan rates (Saskatchewan Physician Payment
Schedule). However, the physician fees may be paid
at Quebec rates with prior approval. In recent years,
the out-of-province reciprocal hospital per diem billing
rates have increased significantly.
4.3
Coverage During Temporary Absences
Outside Canada
Section 3 of the Medical Care Insurance Beneficiary and
Administration Regulations describe the portability of
health insurance provided to Saskatchewan residents
who are temporarily absent from Canada.
Continued coverage for students, temporary workers, and
vacationers and travellers during a period of temporary
absence from Canada is conditional on the registrant’s
intent to return to Saskatchewan residence immediately
on the expiration of the approved period as follows:
• education: for the duration of studies at a recognized educational facility (confirmation by the
facility of full-time student status and expected
graduation date is required);
• contract employment of up to 24 months (written
confirmation from the employer is required); and
travelling within Canada. The cost of travel, meals and
accommodation are not covered.
Prior approval is required for the following services
provided out-of-province:
• alcohol and drug, mental health and problem
gambling services; and
• bone mineral densitometry testing.
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.
• vacation and travel of up to 12 months.
Section 3 of the Medical Care Insurance Beneficiary and
Administration Regulations provides open-ended temporary absence coverage for persons whose principal
place of residence is in Saskatchewan, but who are not
able to satisfy the annual six months physical presence
requirement because the nature of their employment
requires travel from place to place outside Canada (e.g.,
cruise line workers).
Section 6.6 of the Department of Health Act provides the
authority under which a resident is eligible for health
coverage when temporarily outside Canada. In summary,
a resident is eligible for medically necessary hospital
services at the rate of $100 per in-patient and $50 per
out-patient visit per day.
4.4
Prior Approval Requirement
5.0Accessibility
5.1Access 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.
Out-of-Province
The Saskatchewan Ministry of Health continues to place
priority on promoting surgical access and improving the
province’s surgical system.
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
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
90
Canada Health Act — Annual Report 2010–2011
Chapter 3: Saskatchewan
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
patients’ experience across the entire continuum of care
— from initial contact with a health provider, to surgery,
to recuperation in the community.
The plan is based on five objectives: 1) shorter waits
for surgical care; 2) a better experience for patients and
families; 3) safe, high quality care; 4) support for good
health, and 5) patient centred providers. Supporting the
objectives are 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, 2011, there were 1,946 physicians
licensed to practice in the province and eligible to participate in the Medical Care Insurance Plan. Of these,
1,034 (53.1 percent) were family practitioners and
912 (46.9 percent) were specialists.
As of March 31, 2011, there were approximately
387 practising dentists and dental surgeons located
in all major centres in Saskatchewan. Eighty five 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 2010–2011 the
following initiatives were implemented:
• The 2010–2011 budget allocated $1.5 million (from within the $3.5 million Physician
Recruitment Strategy funding) to the Physician
Recruitment Agency of Saskatchewan to provide
recruitment expertise to communities, physician
practices and health agencies.
• 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 Ministry engaged in a dialogue with
stakeholders to begin the development of a
provincially-based program to assess foreigntrained family physicians. The first iteration
of the new program was January 2011.
In addition to the new initiatives noted above, the
Ministry provides various practicing establishment
grants, training grants, and residency positions in
exchange for return-of-service commitments. The
Canada Health Act — Annual Report 2010–2011
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.
• The Northern Medical Services Program is a tripartite endeavour of the Ministry of Health, Health
Canada and the University of Saskatchewan to
help stabilize the supply of physicians in northern
Saskatchewan.
• The Northern Telehealth Network provides physicians in remote or isolated areas with access
to colleagues, specialty expertise and continuing
education.
Other Programs
• 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
The last agreement with the Saskatchewan Medical
Association expired on March 31, 2009. The Ministry
continued to meet with the Association throughout
2010–2011 to reach a new agreement.
Section 6 of the Saskatchewan Medical Care Insurance
Payment Regulations (1994) outlines the obligation of the
Minister of Health to make payments for insured services
in accordance with the Physician Payment Schedule and
the Dentist Payment Schedule.
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
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Chapter 3: Saskatchewan
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 2010–2011 amounted to $747.6 million:
$450.8 million for fee-for-service billings; $27.7 million
for Emergency Coverage Programs; $235.9 million in
non-fee-for-service expenditures; and $33.2 million for
Saskatchewan Medical Association programs. During
2010–2011 negotiations with the Saskatchewan Medical
Association, the Ministry continued to fund and support these programs at the level that was defined in the
expired agreement.
5.3
Payments to Hospitals
Funding to regional health authorities is based on
historical funding levels adjusted for inflation, collective
agreement costs and utilization increases. Each regional
health authority is given a global budget and is responsible for allocating funds within that budget to address
service needs and priorities identified through its needs
assessment processes.
Regional health authorities may receive additional funds
for providing specialized hospital programs (e.g., renal
dialysis, specialized medical imaging services, specialized respiratory services, and surgical services), or
for providing services to residents from other health
regions.
92
Payments to regional health authorities for delivering
services are made pursuant to section 8 of the Regional
Health Services Act. The legislation provides the authority for the Minister of Health to make grants to regional
health authorities and health care organizations for
the purposes of the Act, and to arrange for providing
services in any area of Saskatchewan if it is in the public
interest to do so.
Regional health authorities provide an annual report
on the aggregate financial results of their operations.
6.0 Recognition Given to
Federal Transfers
The Government of Saskatchewan publicly acknowledged
the federal contributions provided through the Canada
Health Transfer (CHT) in the Ministry’s 2010–2011 Annual
Report, the Government of Saskatchewan 2010–2011
Budget and related documents, its 2010–2011 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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Saskatchewan
Registered Persons
1.Number as of March 31st (#). 1
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
1,003,231
1,014,649
1,035,544
1,036,284
1,070,477
Insured Hospital Services Within Own Province or Territory
Public Facilities
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
67
67
67
67
66
2.Number (#).
3.Payments for insured health services ($).
Private For-Profit Facilities
1,173,115,000
2
1,277,632,000
2
1,402,109,000
2
1,556,078,000
2
1,636,013,000
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
4.Number of private for-profit facilities
providing insured health services (#).
0
0
0
0
2
5.Payments to private for-profit facilities
for insured health services ($).
0
0
0
0
0
2
3
Insured Hospital Services Provided to residents in another province or territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
4,627
4,212
4,365
5,722
4,304
36,828,100
31,569,400
43,631,600
53,119,000
48,700,300
52,591
81,787
65,274
71,123
67,689
11,573,400
17,240,900
17,936,200
21,497,100
21,282,400
6.Total number of claims, in-patient (#).
7.Total payments, in-patient ($).
8.Total number of claims, out-patient (#).
9.Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11.Total payments, in-patient ($).
242
245
251
398
295
2,473,400
2,291,200
1,637,300
2,755,200
3,401,000
1,454
1,381
1,437
2,189
1,992
1,019,500
970,500
1,468,500
1,810,000
1,796,700
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
1. Saskatchewan’s numbers as of June 30, 2010.
2. This number includes estimated government funding to Regional Health Authorities (RHAs) based on total projected expenditures less non-government revenue,
as provided to Saskatchewan Health through the RHA annual operational plans.
— Acute care funding includes: acute care services, specialized hospital services, and in-hospital specialist services.
— Does not include inpatient rehabilitative care, in-patient mental health, or addiction treatment services.
— Does not include payments to Saskatchewan Cancer Agency for out-patient chemotherapy and radiation.
3. Private surgical facilities receive payments for insured services under contracts with Regional Health Authorities. The Ministry of Health does not provide payments
to these facilities.
Canada Health Act — Annual Report 2010–2011
93
Chapter 3: Saskatchewan
Insured Physician Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
1,753
1,795
1,836
1,882
1,946
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
17.Total payments for services provided
by physicians paid through all payment
methods ($).
554,193,389
585,863,285
630,253,960
651,437,652
714,441,498
18.Total payments for services provided by
physicians paid through fee-for-service ($).
369,664,529
401,172,658
398,867,624
409,446,758
14.Number of participating physicians (#).
4
407,467,331
4
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
603,687
561,415
599,106
586,621
610,328
24,239,622
25,442,417
27,753,524
29,037,662
31,505,813
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
not available
not available
not available
not available
not available
692,600
637,600
647,700
1,299,600
1,324,100
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
74
82
79
70
85
18,203
16,347
18,085
22,349
17,800
1,511,882
1,577,176
1,840,276
2,013,007
1,827,088
4. 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.
94
Canada Health Act — Annual Report 2010–2011
Chapter 3: ALBERTA
• A new Act called the Alberta Health Act (Act)
received Royal Assent in December 2010 and
is awaiting proclamation. The Act provides
principles to guide the health system, requirements to establish a health charter and a health
advocate, as well as provisions for public input
into the regulations proposed for the Act.
1.0 Public Administration
Alberta
Introduction
Alberta’s Health Care System
In 2010–2011, the Ministry of Alberta Health and
Wellness (Health and Wellness) continued to pursue its
goal of improving the performance and accessibility of
the health system in meeting the needs of Albertans.
Some key achievements include:
• The Government of Alberta released Becoming
the Best: Alberta’s 5-year Health Action Plan in
November 2010. The plan provides Albertans
clear direction on what they can expect from their
health care system over the next five years. The
Plan provides the detailed targets the province
will use to drive further improvements in the
health care system, and is organized under
five core areas:
• Improve access and reduce wait times;
• Provide more options for continuing care;
• Strengthen primary health care;
• Be healthy, stay healthy; and
• Build one health system.
• The Plan is supported by 50 accompanying
performance measures, and is one of the most
aggressive plans to reduce wait times and increase
access anywhere in Canada. The performance
measures include: reduced wait times for hip
surgery; quicker access to radiation oncologists
for cancer patients; faster treatment at emergency
departments; more continuing care spaces; and a
greater emphasis on wellness to keep Albertans
healthy.
Canada Health Act — Annual Report 2010–2011
1.1Health Care Insurance Plan and
Public Authority
Health and Wellness 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
determines which services are covered by the Alberta
Health Care Insurance Plan.
1.2
Reporting Relationship
The Minister of Health and Wellness is accountable for
the Alberta Health Care Insurance Plan. The Government
Accountability Act establishes the planning, reporting and accountability structures that government and
accountable organizations must adhere to.
1.3Audit of Accounts
The Auditor General of Alberta audits all government
ministries, departments, regulated funds and provincial
agencies, and is responsible for assuring the public that
the government’s financial reporting is credible. The
Auditor General of Alberta completed its audit of Health
and Wellness on March 31, 2011, and indicated that
the statements fairly present, in all material respects,
the financial position and results of operations for the
year ended March 31, 2011.
2.0Comprehensiveness
2.1Insured Hospital Services
In Alberta, Alberta Health Services is the body
responsible to the Minister 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
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Chapter 3: ALBERTA
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/documents/
Hospital-Services-Alberta-2011-4.pdf
During 2010–2011, 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.
2.2Insured 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 allowed to
provide insured services under the Alberta Health Care
Insurance Plan.
Alberta had 6,743 fee-for-service physicians who
were billing the Alberta Health Care Insurance Plan
as of March 31, 2011.
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 appropriate governing body
or association, such as 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
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the proposed opting out in a newspaper having general
circulation in the area in which the physician practices
and posting a notice of the proposed opting out in a
part of the physician’s office to which patients have
access, at least 180 days prior to the effective date of
the opting out. A physician who has opted out must
post a notice in part of the physician’s office to which
patients have access advising patients of the physician’s opted out status and ensuring that each patient
is advised of their opted out status before any service
is provided to the patient. As of March 31, 2011, there
were zero opted out physicians in the province.
The Alberta Health Care Insurance Regulation lists
services which are not considered to be either 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 (SOMB), which can be accessed at:
http://www.health.alberta.ca/professionals/SOMB.html
The SOMB is continuously revised. Effective April 1, 2010,
extensive changes were made to the SOMB. All changes
to the SOMB require ministerial approval. Some of the
highlights for these changes included:
• 39 new Health Service Codes, two new modifier
types and four new General Rules;
• 47 deleted Health Service Codes and two deleted
General Rules; and
• 99 amendments to Health Service Codes, 10 amendments to modifiers and 40 amendments to General
Rules.
• The changes outlined above include:
• New Health Service Code for Group Sessions,
multiple patients, where a physician is involved
in providing care and teaching to patients in
attendance.
• A redevelopment and modernization of
the General Surgery and Neurosurgery
schedule items.
• New “corrected age” modifiers to remunerate
surgeons at a higher rate when performing surgery on infants up to three months old corrected
age (i.e., where their chronological age is reduced
by the number of weeks born before 40 weeks
gestation).
• New “L40” modifiers to remunerate surgeons
at a higher rate when performing surgery on
infants under 40 weeks of conceptual age.
Canada Health Act — Annual Report 2010–2011
Chapter 3: ALBERTA
Under the 2003–2011 Tri-lateral Master Agreement,
any changes to the insured physician services listed
in the SOMB were the result of negotiation between
Health and Wellness, the Alberta Medical Association,
and Alberta Health Services. The Agreement expired
on March 31, 2011.
2.3Insured 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. Under section 7
of the Alberta Health Care Insurance Act, all dentists
are deemed to have opted into the Plan. A dentist may
opt out of the plan by notifying the Minister 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, 2011, no dentists were opted out of the
Alberta Health Care Insurance Plan.
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 and Wellness 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.
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
Canada Health Act — Annual Report 2010–2011
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 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, all 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 rank in it; and
• persons serving a term in a federal penitentiary.
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
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Chapter 3: ALBERTA
resident of Alberta. During 2010–2011, no amendments
were made to the legislation regarding eligibility.
All 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 require registrants to provide documentation that
proves their identity, legal entitlement to be in Canada,
and Alberta residency.
As of March 31, 2011, there were 3,786,238 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.
As of March 31, 2011, there were 228 Alberta residents
who were opted out of the Plan.
3.2Other 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 61,404 people covered under these conditions
as of March 31, 2011.
4.0Portability
4.1Minimum 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 for the first
12 months of absence who temporarily leave Alberta
for other parts of Canada. Residents who wish to
maintain coverage for a longer period may apply for
an extension.
98
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 and Wellness 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 2010–2011, no amendments were made to the legislation regarding in-Canada portability. More information
on coverage during temporary absences outside Alberta
is available at:
http://www.health.alberta.ca/AHCIP/
Q-coverage-outside-Alberta.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
2010–2011.
4.3
Coverage During Temporary Absences
Outside Canada
The Alberta Health Care Insurance Plan provides
coverage to eligible Alberta residents for the first
six consecutive months of temporary absence from
Canada. Residents who wish to maintain coverage
for a longer period may apply for an extension of
coverage.
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 and Wellness of their
permanent and principal place of residence within the
province.
Canada Health Act — Annual Report 2010–2011
Chapter 3: ALBERTA
The maximum amount payable for out-of-country inpatient 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 $472 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 process that evaluates reimbursement
requests by Alberta residents for medically necessary
services which are covered under the Alberta Health
Care Insurance Plan, but are not available in Canada.
More information on coverage during temporary
absences outside Canada is accessible at:
http://www.health.alberta.ca/AHCIP/
Q-coverage-outside-Alberta.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 2010–2011.
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 for insured services that are
medically required, are not experimental, and are not
available in Alberta or elsewhere in Canada.
5.0Accessibility
5.1Access 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
Canada Health Act — Annual Report 2010–2011
the province, working in partnership with Health and
Wellness to ensure all Albertans have equal access to
health services across the province.
Health and Wellness 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 will include renovations to create
additional ambulatory treatment space.
• A new health centre in Edson, which will be built
on a new site to provide health care services and
programs to meet the needs of the community,
including acute care, emergency and out-patient
services.
• A new health centre in High Prairie to replace
the existing complex and the J.B. Wood Nursing
Home. The new High Prairie Health Centre will be
built on a new site and will include a wide range
of health services such as acute care, continuing
care and community health programs.
• A new regional hospital in Grande Prairie, which
will include a state-of-the-art cancer centre.
• The addition of 1,166 new and upgraded spaces
to Alberta’s continuing care system to address the
needs of an aging population. New construction or
renovations involving 13 facilities were initiated
across 11 Alberta communities.
• 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;
Wetaskiwin PCN and Vermilion PCN were launched
on September 1, 2010; Grande Prairie PCN was
launched on October 1, 2010; 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.
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Chapter 3: ALBERTA
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 the negotiation. The Agreement established
overall increases to compensation under the fee-forservice and ARPs streams. 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, teambased approaches to service delivery, access to services,
patient satisfaction, and value for money. ARPs provide
predictable funding that enables physician groups to
recruit new physicians to their programs and retain
their services. ARPs are unique in that they offer an
alternative funding model to the way government has
traditionally funded health care service delivery. (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 Primary Care Networks
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 the Ministry when the 2003–2011 agreement expired, is not intended to compensate physicians
for the provision of insured services although physicians can receive payment for uninsured services
related to work done on behalf of the PCN.
The 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. The Ministry
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 and
Wellness establishes fees through a consultation process with the Alberta Dental Association and College.
100
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 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
are 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 2010–2011 publications.
Canada Health Act — Annual Report 2010–2011
Chapter 3: ALBERTA
Registered Persons
1.Number as of March 31st (#).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
3,384,625
3,473,996
3,589,494
3,692,001
3,786,238
Insured Hospital Services Within Own Province or Territory
Public Facilities
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
204
204
251
248
250
not available
not available
not available
not available
not available
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
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 ($).
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
4,608
5,334
5,447
5,411
5,689
22,005,293
27,481,524
31,475,940
33,077,528
37,887,391
82,710
101,455
104,127
105,792
110,757
14,305,024
18,004,246
25,346,678
26,879,756
29,382,381
6.Total number of claims, in-patient (#).
7.Total payments, in-patient ($).
8.Total number of claims, out-patient (#).
9.Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada1
10.Total number of claims, in-patient (#).
11.Total payments, in-patient ($).
3,698
4,014
4,762
4,506
3,075
2
336,859
378,043
446,718
425,269
294,509
2
3,816
3,934
4,305
4,544
3,425
2
224,761
214,162
291,836
306,639
267,120
2
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
1. These data do not include claims/payments for Alberta residents who have received health services out of country through the Out-of-Country Health Services
Committee application process. 2. Data for out of country hospital and physician services are lower than anticipated due to claims for 2010–2011 still being processed.
Canada Health Act — Annual Report 2010–2011
101
Chapter 3: ALBERTA
Insured Physician Services Within Own Province or Territory
Public Facilities
14.Number of participating physicians (#).
15.Number of opted-out physicians (#).
16.Number of non-participating physicians (#).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
5,850
6,058
6,266
6,482
6,743
3
not applicable
4
not applicable
4
not applicable
4
not applicable
4
not applicable
4
0
0
0
0
0
17.Total payments for services provided
by physicians paid through all payment
methods ($).
not available
not available
not available
not available
not available
18.Total payments for services provided by
physicians paid through fee-for-service ($).
1,558,128,163
1,718,717,023
1,851,703,042
2,133,199,354
2,302,481,210
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
463,410
548,423
696,639
599,596
611,503
17,450,377
20,899,683
22,614,491
24,621,807
25,340,583
Insured Physician Services Provided Outside Canada5
21.Number of services (#).
22.Total payments ($).
22,909
22,055
22,817
22,070
15,654
6
1,054,544
1,105,831
1,245,840
1,266,451
909,715
6
Insured Surgical-Dental Services Within Own Province or Territory
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
220
207
202
212
207
16,783
16,769
18,705
18,963
21,052
3,637,243
3,913,975
4,479,725
4,847,467
5,747,026
3. There are 7,413 physicians registered with the Alberta Health Care Insurance Plan (AHCIP): 6,743 of the 7,413 bill fee-for-service; 1,688 of the 7,413 participate in
Alternate Relationship Plans (ARPs); and 2,216 of the 7,413 participate in Primary Care Networks (PCNs).
4. Alberta’s legislation does not contemplate an “opted-out” status that aligns with the definition of this indicator. 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, 2011 there were zero non-participating physicians in Alberta, as noted in indicator 16.
5. These data do not include Alberta residents who have received health services out of country through the Out-of-Country Health Services Committee application process.
6. Data for out of country hospital and physician services are lower than anticipated due to claims for 2010–2011 still being processed.
102
Canada Health Act — Annual Report 2010–2011
Chapter 3: British Columbia
British Columbia
Introduction
The British Columbia health system is one of our most
valued social programs; virtually every person in the
province will access some level of health care or health
service during their lives. 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 Ministry directly
manages a number of provincial programs and services.
These programs include: the Medical Services Plan, which
covers most physician services; PharmaCare, which provides prescription drug insurance for British Columbians;
the BC Vital Statistics Agency, which registers and reports
on vital events such as a birth, death or marriage; and
HealthLink BC, a confidential, non-emergency health
information, advice, and health system navigation platform providing multi-disciplinary comprehensive self-care
service. It is available 24/7 by telephone (8-1-1), on the
web (www.healthlinkbc.ca), and in print resources (BC
HealthGuide Handbook).
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
Canada Health Act — Annual Report 2010–2011
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. These include the specialized programs
and services provided through the following agencies:
Emergency and Health Services Commission which operates both BC Ambulance Service and BC Bedline, the
provincial acute bed management system; BC Cancer
Agency; BC Centre for Disease Control; BC Children’s
Hospital and Sunny Hill Health Centre for Children;
BC Women’s Hospital and Health Centre; BC Provincial
Renal Agency; BC Transplant Society; Cardiac Services
BC; BC Mental Health and Addiction Services including
Riverview Hospital and the Forensic Psychiatric Services
Commission; and Perinatal Services BC.
In 2010–2011, the Government of British Columbia
invested $16.15 billion to meet the health needs of
British Columbians. This expenditure was made across
a wide spectrum of programs and services aligned with
the Ministry’s goals. 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.
The following section highlights significant achievements
in 2010–2011 in areas relevant to the Canada Health Act
Annual Report: providing increased access to care, innovation in health care, and health human resources.
Access to care:
• Opened the $9.4 million renal unit at Nanaimo
Regional General Hospital, benefitting kidney
patients across Central and Northern Vancouver
Island, and opened the $349 million Patient Care
Centre at Royal Jubilee Hospital in Victoria.
• Completed the $4.3 million newly redeveloped
Invermere and District Hospital emergency
department, doubling the size of the emergency
department and improving patient flow, and
completed the $24.7 million Shuswap Lake
General Hospital redevelopment.
• Began construction on the new $36.9 million
emergency department at Nanaimo Regional
General Hospital, and worked with Canuck
Place, the Provincial Health Services Authority,
the Ministry of Children and Family Development,
and the Fraser Health Authority to guide the
expansion of hospice services for children in
British Columbia.
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• Increased investment in cancer care and control
through the BC Cancer Agency by 151 percent since
2000–2001. Began construction on the $106 million
BC Cancer Agency for the North, which will eliminate the need for northern residents to travel south
for treatment.
• Reached a new agreement with emergency room
physicians, providing an increase to the number
of doctors in 19 emergency departments across
the province. Over the 2010–2011 and 2011–2012
fiscal years, the Province’s funding commitment
will increase by up to $12 million for physician services in the affected hospitals over the two years.
• Continued to close the gap in health status
between Aboriginal peoples and the rest of the
British Columbia population by negotiating
the BC Framework Agreement on First Nations
Health Governance, which outlines the transfer
of health resources to First Nations, to enable
and empower First Nations people to better
govern their own health and well-being.
• Launched a new surgical wait times website,
which helps patients work with their general
practitioners to decide whether there is a faster
or more appropriate treatment available, and
helps health authorities and the Province make
decisions about funding and surgical resource
allocation.
• Increased guideline-based care by family physicians; for example, planned chronic disease or
complex care was provided to 575,894 patients
as at February 2011, which is ten percent higher
than at February 2010.
Innovation in health care:
In early 2010, British Columbia embarked on an innovation and change agenda, which is based on two key
actions: 1) Where possible and appropriate, British
Columbia can lower cost, improve patient outcomes,
and improve patient experience by moving patient care
from high cost, high intensity services such as hospital
care to lower cost services within the community, and
2) Improve the efficiency of the system and drive innovation while continuing to meet the needs of the British
Columbia population.
The innovation and change agenda is showing results:
• Patient-focused funding was introduced in
April 2010 to provide quicker emergency
department care, reduce surgery wait times,
and increase the number of same-day
surgical procedures where appropriate.
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With 2010–2011 patient-focused funding, an
additional 36,000 patients received surgeries and
diagnostic care and an additional 67,000 emergency department patients were seen within the
targeted wait times.
• More than 125 Lean events were held across
the province aimed at improving workflow and
efficiency, improving services to patients, and
reducing costs in the health system.
• Through initiatives such as active waitlist management and Activity-Based Funding, British Columbia
has increased the number of hip replacements from
4,478 in 2009–2010 to 4,600 in 2010–2011. Over
400 more knee joint replacements were completed
from the previous fiscal year and the 90th percentile wait time dropped by 3.7 weeks.
• The Province is providing help to British Columbia
smokers who want to quit as part of its prevention initiative. The Prescription for Health
program helps primary care providers give British
Columbia doctors additional tools to help support
those patients who smoke, are physically inactive, obese, or have unhealthy eating practices.
QuitNow Services offers free smoking cessation
supports 24 hours a day through web, text, and
telephone services.
• The Province negotiated an agreement with the
community pharmacy sector that will reduce the
price of generic drugs in British Columbia, and
save the British Columbia health system tens of
millions of dollars per year.
Health human resources:
• Since 2004, the University of British Columbia (UBC)
medical school has more than doubled the number of
first-year seats for undergraduate medical students
to 256, and distributed training programs outside the
Lower Mainland to the Northern Medical Program
in Prince George, the Island Medical Program in
Victoria, and the Southern Medical Program which
opened in the Okanagan in September 2011. By
2015, approximately 1,150 medical students are
expected to be in training at any one time in BC.
• Growth in postgraduate medical education (residencies) has kept pace with undergraduate expansion.
Since 2004, British Columbia has more than doubled
the number of first-year residencies for Canadian
medical graduates to 256, and tripled the number
for international medical graduates (IMG) to 19.
• Starting in 2011, the IMG-BC Program is expected
to expand and distribute its program by an additional 40 first-year residencies in family medicine
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Chapter 3: British Columbia
over the next five years. By 2015, 1,200 residents
are expected to be in training at any one time, and
by 2020, over 300 new physicians are expected to
be ready to enter practice each year.
• The College of Physicians and Surgeons of British
Columbia reported 10,726 professionally active
physicians in British Columbia in 2010.
1.0 Public Administration
1.1Health Care Insurance Plan and
Public Authority
The British Columbia Medical Services Plan (MSP)
is administered by the British Columbia Ministry
of Health. MSP insures medically required services
provided by physicians and supplementary health
care practitioners, laboratory services, and diagnostic
procedures. The Ministry of Health 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 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, under MSP, reasonable access to quality
medical care, health care, and diagnostic 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.
1.2
Reporting Relationship
The Medical Services Commission (MSC) 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
Canada Health Act — Annual Report 2010–2011
is published annually: it contains an alphabetical listing of
payments made by the MSC to practitioners, groups, clinics, hospitals, and diagnostic facilities for each fiscal year.
The Ministry of Health (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;
• Health Authority Government Letters of Expectations
and Reports;
• Provincial Health Officer’s Annual Report (on the
health of the population);
• Nationally Comparable Indicators Report (Canadian
Institute for Health Information); and
• Medical Services Commission Annual Report.
1.3Audit of Accounts
The Ministry is subject to audit of accounts and financial
transactions through:
• The Office of the Comptroller General’s 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 Office of the Auditor General (OAG) of British
Columbia is responsible for conducting audits and
reporting its findings to the Legislative Assembly.
The OAG initiates its own audits and the scope of
its audits. The Public Accounts Committee of the
Legislative Assembly reviews the recommendations
of the OAG and determines when the Ministry has
complied with the audit recommendations.
1.4Designated 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 2010–2011 fiscal year.
Revenue Services of British Columbia (RSBC) performs
revenue management services, including account management, billing, remittance and collection, on behalf of
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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.
In 2005, the Ministry of Health contracted with MAXIMUS
BC to deliver the operations of the Medical Services Plan
and PharmaCare (including responding to public inquiries, registering clients, and processing medical and
pharmaceutical claims from health professionals). The
new organization is called Health Insurance BC (HIBC).
Policy and decision-making functions remain with the
Ministry of Health (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 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
2.1Insured 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 provides 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
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“general hospital services” which are to be provided
as benefits.
Hospital services are insured when they are provided
to a beneficiary, in a publicly funded hospital and are
deemed medically required by the attending physician
or midwife. These services are provided to beneficiaries without charge, with the exception of incremental
charges for preferred, but not medically required,
medical/surgical supplies, nonstandard accommodation
when not medically required and, for residential care
patients in extended care or general hospitals, a daily
fee based on income.
General hospital services and the conditions under
which they are provided are described in the Hospital
Insurance Act Regulations and include the following
for in-patients: accommodation and meals at the standard or public ward level; necessary nursing services;
laboratory and radiological procedures and necessary
interpretations together with such other diagnostic
procedures as approved by the Minister in a particular
hospital with the necessary interpretations, for maintaining health, preventing disease and helping diagnose
and treat illness, injury or disability; drugs, biological,
and related preparations; routine surgical supplies;
use of operating room and case room and anaesthetic
facilities, including necessary equipment and supplies;
use of radiotherapy and physiotherapy facilities, where
available; and other services approved by the Minister.
The following out-patient general hospital services are
also insured: day care surgical services; out-patient
renal dialysis treatments in designated hospitals or
other approved facilities; diabetic day-care services in
designated hospitals; out-patient dietetic counselling
services at hospitals with qualified staff dieticians; psychiatric out-patient and day-care services; rehabilitation
out-patient services; cancer therapy and cytology services;
out-patient psoriasis treatment; abortion services; and
magnetic resonance imaging (MRI) services. In addition,
a wide variety of out-patient clinic services are insured
when delivered in a hospital.
Insured services in rehabilitation hospitals include:
accommodation and meals at the standard or public ward
level; necessary nursing services; drugs, biologicals and
related preparations; use of physiotherapy and occupational therapy facilities; laboratory and radiological
procedures and necessary interpretations together with
such other diagnostic procedures as approved by the
Minister in a particular hospital with the necessary
interpretations, for maintaining health, preventing
disease, and helping diagnose and treat illness, injury,
or disability; and other services approved by the
Minister.
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Chapter 3: British Columbia
Insured services in extended care hospitals include:
accommodation and meals at the standard ward level;
necessary nursing services; drugs, biologicals, and related
preparations; laboratory and radiological procedures
and necessary interpretations together with such other
diagnostic procedures as approved by the Minister in a
particular hospital with the necessary interpretations,
for maintaining health, preventing disease and helping
diagnose and treat illness, injury, or disability; and other
services approved by the Minister.
Insured hospital services do not include: transportation
to and from hospital (however, ambulance transfers are
insured under another Ministry program, with a small
user charge); services or treatment that the Minister, or
a person designated by the Minister, determines, on a
review of the medical evidence, the beneficiary does not
require; services or treatment for an illness or condition
excluded by regulation of the Lieutenant Governor in
Council; and services provided to non-beneficiaries.
No new hospital services were added during the
2010–2011 fiscal year. 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. There is a formal process
to add specific medical services (physician fee items) to
the list of services insured under the Medicare Protection
Act, and this process is described in Section 2.2 of this
report.
2.2Insured 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
practitioners, such as midwives) who are enrolled 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) by a medical
practitioner enrolled with MSP; and
Canada Health Act — Annual Report 2010–2011
• 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 2010–2011, 9,417 physicians (includes only
general practitioners and medical specialists who billed
fee-for-service (FFS) in 2010–2011) were enrolled with
MSP and billed FFS. In addition, some physicians practice
solely on salary, receive sessional payments, or are on
contract (service agreements) with the health authorities.
Physicians paid by these alternative mechanisms may
also practice on a FFS basis. Non-physician healthcare
practitioners who may be enrolled to provide insured services under MSP are midwives and supplementary benefit
practitioners (dental surgeons, optometrists, osteopaths,
surgical podiatrists, and acupuncture practitioners). Only
those MSP beneficiaries with premium assistance status
qualify for MSP coverage of physiotherapy, massage
therapy, chiropractic, naturopathy, acupuncture, and
non-surgical podiatry services. In 2010–2011, there
were 180 midwives and 6,071 supplementary benefits
practitioners paid FFS through MSP.
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 MSC. Patients are responsible for the
full cost of services provided by non-enrolled physicians.
In 2010–2011, MSP had 5 opted-out physicians. Based
on reclassification of information and corresponding
data, British Columbia does not track non-participating
physicians.
Enrolled physicians can elect to be paid directly by
patients by giving written notice to MSC. 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 Master Agreement between the government,
MSC, and the British Columbia Medical Association
(BCMA), modifications to the Payment Schedule such as
additions, deletions or fee changes are made by 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
MSC for new procedures or other services for a limited
period of time while definitive listings are established.
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During fiscal year 2010–2011, physician services which
were added as MSP insured benefits included 116 new
fee items which reflect current practice standards,
for example:
• Obstetrical B scan >14 weeks with Nuchal
translucency measurement;
• General Surgery lysis of intra-abdominal
adhesions;
• Specialist group medical visits; and
• Cardiovascular risk assessment.
2.3Insured 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 surgical-dental procedures are those
related to remedying a disorder of the oral cavity or
a functional component of mastication. Generally this
would include: oral surgery related to trauma; orthognathic surgery; medically required extractions; and
surgical treatment of temporomandibular joint dysfunction. No new insured surgical-dental services were
added during the fiscal year 2010–2011. 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
Medical Services Commission.
Any general dental and/or oral surgeon in good standing
with the College of Dental Surgeons and enrolled in MSP
may provide insured surgical-dental services in hospital.
There were 236 dentists (includes only oral surgeons,
dental surgeons, oral medicine, and orthodontists)
enrolled with MSP and billing FFS in 2010–2011.
2.4
Uninsured Hospital, Physician and
Surgical-Dental Services
Medical necessity, as determined by the attending physician and hospital, is the basis for access to hospital
and medical services.
For out-patients, take-home drugs and certain hospital
drugs are not insured, except those provided under
the provincial PharmaCare program. Other procedures
not insured under the Hospital Insurance Act include:
services of medical personnel not employed by the hospital; treatment for which Worksafe BC, the Department
of Veterans Affairs, or any other agency is responsible;
services solely for the alteration of appearance; and
reversal of sterilization procedures. Uninsured hospital
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services also include: preferred accommodation at the
patient’s request; televisions, telephones, and private
nursing services; preferred medical/surgical supplies;
dental care that could be provided in a dental office
including prosthetic and orthodontic services; and,
preferred services provided to patients of extended
care units or hospitals.
Services not insured under the Medical Services Plan
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.”
The Ministry of Health (the Ministry) responds to
complaints made by patients and takes appropriate
actions to correct situations identified to the Ministry.
The MSC determines which services are benefits and
has the authority to de-list insured services. Proposals to
de-insure services must be made to MSC. Consultation
may take place through a sub-committee of MSC and
usually includes a review by the BCMA’s Tariff Committee.
In 2010–2011, 65 obsolete fee items were removed from
the Fee Schedule. The fee items which were removed
included those for out-dated technology in the Laboratory,
Ophthalmology, and Orthopaedic Sections, amongst
others.
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;
Canada Health Act — Annual Report 2010–2011
Chapter 3: British Columbia
• 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), or serving a
term of imprisonment in a penitentiary as defined in
the Penitentiary Act, are eligible for federally funded
health insurance. The Medical Services Plan (MSP) provides first-day coverage to discharged members of the
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, 2011, was 4,521,503.
3.2Other Categories of Individual
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,
Canada Health Act — Annual Report 2010–2011
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, 2011, are
$60.50 for one person, $109 for a family of two, and
$121 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 holder
of permanent resident (landed immigrant) status under
the (federal) Immigration and Refugee Protection Act.
4.0Portability
4.1Minimum 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 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 2010–2011, 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
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Chapter 3: British Columbia
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 British Columbia residents, upon
presentation of a valid MSP 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.
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.
The Medical and Health Care Services Regulation was
amended by British Columbia Regulation 111/2005.
The relevant issues addressed by the amendments are
as follows:
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 BC must
return to the province by the end of the month following the month in which studies are completed. Any
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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 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 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 Commission 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-ofProvince 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.
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Chapter 3: British Columbia
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
for anorexia) may require the approval 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
5.1Access 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:
In 2010–2011, approximately 3,000 general practitioners
(GPs) and specialists received all or part of their income
through British Columbia’s Alternative Payments Program
(APP). APP funds regional health authorities to hire salaried physicians or contract with physicians, in order to
deliver insured clinical services.
The Ministry implemented several programs under
the 2002 Subsidiary Agreement for Physicians in Rural
Practice, which were continued in the Physician Master
Agreements (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, which provides eligible
physicians (estimated at 1,300) 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.
• Northern and Isolation Travel Assistance Outreach
Program, which provides funding support for
approved physicians who visit rural and isolated
communities to provide medical service(s).
• Rural General Practitioner Locum Program,
which 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.
Canada Health Act — Annual Report 2010–2011
• Rural Specialist Locum Program, which 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.
• Rural Education Action Plan, which supports the
training needs of physicians in rural practice. This
program supports training in physicians’ rural
practices through several components, including
rural practice experience for medical students
and enhanced skills for practicing physicians.
• Isolation Allowance Fund, which 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.
• Rural Loan Forgiveness Program, which decreases
British Columbia student loans by 20 percent for
each year of rural practice for physicians, nurse
practitioners, nurses, midwives, and pharmacists.
The Full-Service Family Practice Incentive Program has
been expanded as the Ministry of Health and physicians
continue to work together to develop incentives aimed at
helping to support and sustain full service family practice.
In 2010–2011, further new and revised fees were in place
to support general practitioners in providing primary care
to their patients. As of March 31, 2011, 2,689 general
practitioners (GPs) billed the Annual Complex Care
fee (14033) for 141,838 patients, and 2,302 GPs participated in the Mental Health Planning Fee, developing
a mental health plan for 77,273 patients. There were
eight conferencing and planning fees available and
billed for 12,429 patients in facilities, acute care,
or palliative care.
Infrastructure and Capital Planning:
British Columbia continues to make strategic investments
in health sector capital infrastructure. The Ministry of
Health 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 is developing a ten year capital plan to ensure
health infrastructure is maintained and renewed within
expected asset lifecycle timelines.
As noted in the Introduction section of the report, the
Ministry has committed to a significant number of major
capital projects at hospitals in locations including Victoria,
Surrey, Abbotsford, Vancouver, Prince George, Vernon,
111
Chapter 3: British Columbia
Kelowna, 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.
The province is nearing completion of the construction
on a new cancer treatment centre in Prince George and
is in the process of procurement for a new cardiac care
centre in Kelowna. These projects represent an extension of strategic health services and reduce the need for
patients to travel to the Vancouver area for treatment.
British Columbia has also started construction on a
new Critical Care Tower at Surrey Memorial Hospital
to accommodate an expanded emergency department,
neonatal intensive care beds, and acute care beds.
5.2
Physician Compensation
Through negotiations with the British Columbia Medical
Association (BCMA), British Columbia established the
compensation and benefit structure for physicians who
perform publicly funded medical procedures. In 2007,
as provided for by the 2006 Letter of Agreement, the
Province and the BCMA concluded negotiations for a
Physician Master Agreement (PMA). The PMA remains
in effect until 2012. In addition to the PMA, the Province
and the BCMA also have five subsidiary agreements:
General Practitioners Subsidiary Agreement; Specialists
Subsidiary Agreement; Rural Practice Subsidiary Agree­
ment; Alternative Payments Subsidiary Agreement;
and Benefits Subsidiary Agreement. These agreements
address matters unique to each aspect of medicine
addressed by an individual subsidiary agreement. All
five subsidiary agreements terminate in 2012 along
with the PMA.
Being long-term, the PMA provides support for a more
structured relationship between the BCMA and the
Province than had been in place previously. Health
authorities have a larger role in making decisions
which affect health care in their respective regions.
A main focus of the PMA is the establishment of mech­
anisms which promote enhanced collaboration and
accountabilities between the province and the BCMA.
Key to the success of these mechanisms is a strengthened conflict resolution process.
British Columbia anticipates additional benefits from
the new PMA structure including: efficiencies stemming
from the amalgamation of most agreements with the
BCMA into a single agreement framework; streamlining
112
committee structure and communication; providing a
formal conflict management process which addresses
issues at both the local and provincial levels; limiting
physician service withdrawals; and establishing a structured process for physicians wishing to change their
method of compensation to better align with strategies
and priorities of the Province and of health authorities.
Effective April 1, 2009, physician compensation rates
were increased by 3 percent. Over the life of the PMA,
the province also provides financial support targeted
towards: increasing rural physician incentive programs;
providing for new fee items; increasing physician benefit programs; supporting full service family practices;
and improving information technology and promoting
eHealth initiatives.
Medical practitioners are licensed under the Health
Professions Act. A Payment Schedule for medical practitioners is established under section 26 of the Medicare
Protection Act and is referred to in the Second Master
Agreement between the Government of British Columbia,
the Medical Services Commission, and the British
Columbia Medical Association.
Dentists are licensed under the Health Professions
Act. The province and the British Columbia Dental
Association (BCDA) negotiated a Memorandum of
Understanding in 2007 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
APP to health authorities for physicians’ services. Over
74 percent of medical expenditures were distributed
as fee-for-service and 11 percent were distributed
as alternative payments. Of the alternative payments,
77 percent were distributed through contracts, 21 percent
as sessions (3.5-hour units of service), and 2 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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: British Columbia
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 services for the population of the region (or for specific provincial services, for
the population of British Columbia), including the provision of hospital services. The Hospital Insurance Act
and its related regulations 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.
As noted in the Introduction of this report, in April 2010,
the Ministry of Health (the Ministry) introduced patientfocused funding under which a significant portion of
eligible acute care funding is based on actual workload
performed. By 2013, it is expected that around 20 percent of acute care funding (or ten percent of total funding
to health authorities) will be allocated using the patientfocused funding methodology.
Annual funding allocations to health authorities are determined as part of the Ministry of Health’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 of Health’s Population Needs-Based Funding
Formula and other funding allocation methodologies
(e.g. to reflect targeted funding allocations directed to
Canada Health Act — Annual Report 2010–2011
specific health authorities). The annual funding allocation to health authorities does not include funding for
programs directly operated by the Ministry of Health,
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
2010–2011, a full continuum of care (acute, residential,
community care, public and preventive health, adult
mental health, addictions programs, etc.) was provided.
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 2010–2011, these documents included:
• 2010–2011 Third Quarterly Report, available at:
http://www.fin.gov.bc.ca/qrt-rpt/qr10/Q3_10.pdf
• Estimates, Fiscal Year Ending March 31, 2011,
available at:
http://www.bcbudget.gov.bc.ca/2010/estimates/
2010_Estimates.pdf
• 2010–2011 Budget and Fiscal Plan, available at:
http://www.bcbudget.gov.bc.ca/2010/bfp/
2010_Budget_Fiscal_Plan.pdf
• Public Accounts 2010–2011, available at:
http://www.fin.gov.bc.ca/OCG/pa/10_11/
Pa10_11.htm
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Chapter 3: British Columbia
Registered Persons
1.Number as of March 31st (#).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
4,279,734
4,335,676
4,402,540
4,469,177
4,521,503
Insured Hospital Services Within Own Province or Territory
Public Facilities
2006–2007
2.Number (#).
120
3.Payments for insured health services ($). 2
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 ($).
2007–2008
1
120
2008–2009
1
119
2009–2010
119
1
2010–2011
119
1
not available
not available
not available
not available
not available
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
22
not available
not available
not available
not available
not available
not available
not available
not available
not available
1
Insured Hospital Services Provided to residents in another province or territory
6.Total number of claims, in-patient (#).
7.Total payments, in-patient ($).
8.Total number of claims, out-patient (#).
9.Total payments, out-patient ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
7,172
7,160
7,102
6,846
5,909
65,678,542
55,309,733
64,550,692
64,655,739
67,078,612
81,878
95,677
95,326
87,948
78,075
17,937,647
19,088,368
24,262,195
24,188,890
21,830,298
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11.Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
1,858
1,603
1,963
3,056
2,469
3,452,739
14,486,341 11,811,654
6,058,867
4,452,628
960
1,215
1,630
1,920
1,940
453,698
553,661
967,704
1,174,112
999,733
General information for statistical indicators 1-2: Historical and current data may differ from report to report because of changes in data sources, definitions and
methodology from year to year. The count of facilities in this table may not match counts produced from the Discharge Abstract Database, the MIS reporting system,
or the Societies Act because each reporting system has different approaches to counting multiple site facilities and categorizing them by function.
1. As per the guidelines, the number of public facilities in this table excludes psychiatric hospitals and extended care facilities.
2. BC Ministry of Health Funding to Health Authorities for the provision of the full range of regionally delivered services are as follows: $7.1 billion in 2006–2007,
$7.64 billion in 2007–2008, $8.2 billion in 2008–2009, $8.6 billion in 2009–2010, and $8.94 billion in 2010–2011.
114
Canada Health Act — Annual Report 2010–2011
Chapter 3: British Columbia
Insured Physician Services Within Own Province or Territory
2006–2007
14.Number of participating physicians (#).
8,626
2007–2008
3
8,772
2008–2009
3
8,986
2009–2010
9,201
3
2010–2011
9,417
3
15.Number of opted-out physicians (#).
5
5
5
5
5
16.Number of non-participating physicians (#).
1
2
2
2
not available
17.Total payments for services provided
by physicians paid through all payment
methods ($).
not available
not available
not available
not available
not available
18.Total payments for services provided by
physicians paid through fee-for-service ($).
2,136,478,686
5
2,234,652,895
5
2,334,513,866
5
2,460,945,514
5
2,541,920,220
3
4
5
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
869,076
724,900
735,829
622,229
624,569
27,402,618
26,464,075
28,703,587
29,591,572
30,719,900
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
80,810
84,204
82,654
75,190
41,369
3,739,839
4,379,977
4,528,057
3,880,760
2,151,509
Insured Surgical-Dental Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
234
245
249
243
236
44,015
43,262
46,736
50,341
51,036
6,087,395
6,305,343
7,289,302
8,093,266
7,991,262
23.Number of participating dentists (#).
24.Number of services provided (#).
25.Total payments ($).
3. The number of participating physicians in item 14 is for physicians who received payments through Fee-For-Service.
4. Based on reclassification of information and corresponding data, BC does not track non-participating physicians. Data for item number 16 is not available.
5. 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 2010–2011
115
116
Canada Health Act — Annual Report 2010–2011
Chapter 3: Yukon
interested in pursuing a career in a medical profession
to remain in Yukon. Training LPNs locally is helping us
address Yukon’s demand for health care professionals,
particularly in continuing care and home care.
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 hereafter referred
to as the Director, Insured Health and Hearing
Services. References in this text to the “Plan” refer
to either the Yukon Health Care Insurance Plan
or the Yukon Hospital Insurance Services Plan.
The objective of the Yukon health care system is to
ensure access to, and portability of, insured physician
and hospital services according to the provisions of
the Health Care Insurance Plan Act and the Hospital
Insurance Services Act. The Minister, Health and Social
Services, is responsible for delivering all insured health
care services. Service delivery is administered centrally
by the Department of Health and Social Services.
Other insured services provided to eligible Yukon residents include the Children’s Drug and Optical Program;
the Chronic Disease and Disability Benefits Program;
the Pharmacare and Extended Benefits Programs; and
the Travel for Medical Treatment Program. Non-insured
health service programs include Community Health;
Community Nursing; Continuing Care; and Mental
Health Services.
In February 2009, the Yukon government launched
a four-year Licensed Practical Nurse (LPN) program
at Yukon College to encourage Northerners who are
Canada Health Act — Annual Report 2010–2011
The Yukon Hospital Corporation is investing approximately $70 million for three major infrastructure projects:
construction of the Residence for Visiting Health Care
Professionals and Staff Office Complex in Whitehorse,
and the construction of two new Regional Hospitals in
Dawson City and Watson Lake.
The Yukon government is also utilizing modern technology to improve health care services for Yukoners.
It has invested in teleradiology 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 has also
introduced the Weight Wise program to the territory.
A local physician and a local nurse were trained to
deliver the program by Alberta Health Services, which
also provides the Weight Wise program to its clients.
The Weight Wise program is a 10-module re-education
series for obese patients. It 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. Fifteen clients participated in
the first intake of the program.
1.0 Public Administration
1.1Health 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 2010–2011.
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 2010–2011.
117
Chapter 3: Yukon
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:
• develop and administer the Plan;
• determine eligibility for entitlement to insured
health services;
• register persons in the Plan;
• make payments under the Plan, including the
determination of eligibility and amounts;
• determine the amounts payable for insured
health services outside the Yukon;
• establish advisory committees and appoint
individuals to advise or assist in the operation
of the plan;
• conduct actions and negotiate settlements in the
exercise of the Government of Yukon’s right of
subrogation under the Act to the rights of insured
persons;
• conduct surveys and research programs and
obtain statistics for such purposes;
• establish what information is required to be provided under the Act and the form that information
must take;
• appoint inspectors and auditors to examine and
obtain information from medical records, reports,
and accounts; and
• perform any other functions and discharge any
other duties assigned by the Minister of Health
and Social Services under the Act.
Subject to the Hospital Insurance Services Act (section 6)
and the regulations, the mandate and function of the
Director, Insured Health and Hearing Services, is to:
• develop and administer the hospital insurance plan;
• determine eligibility for and entitlement to insured
services;
• determine the amounts that may be paid for the cost
of insured services provided to insured persons;
• enter into agreements on behalf of the Government
of Yukon with hospitals in or outside of Yukon, or
with the Government of Canada or any province or
an appropriate agency thereof, for the provision of
insured services to insured persons;
• conduct surveys and research programmes and
obtain statistics for those purposes;
• appoint inspectors and auditors to examine and
obtain information from hospital records, reports,
and accounts;
• prescribe the forms and records necessary to carry
out the provisions of the Act; and
• perform any other functions and discharge any
other duties assigned to the administrator by the
Regulations.
1.2
Reporting Relationship
The Department of Health and Social Services is
accountable to the Legislative Assembly and the
Government of Yukon through the Minister.
Section 6 of the Health Care Insurance Plan Act and
section 7 of the Hospital Insurance Services Act require
that the Director, Insured Health and Hearing Services,
make an annual report to the Minister of Health and
Social Services respecting the administration of the two
health insurance plans. A Statement of Revenue and
Expenditures is tabled in the legislature and is subject
to discussion at that level.
1.3Audit of Accounts
The Health Care Insurance Plan and the Hospital
Insurance Services Plan are subject to audit by the
Office of the Auditor General of Canada. The Auditor
General of Canada is the auditor of the Government
of Yukon in accordance with section 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;
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Canada Health Act — Annual Report 2010–2011
Chapter 3: Yukon
2.0Comprehensiveness
2.1Insured 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 2010–2011.
In 2010–2011, 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 is operated
under a three-year accreditation through the Canadian
Council on Health Services Accreditation. The surveyors
did an accreditation review for renewal in May 2010.
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
Canada Health Act — Annual Report 2010–2011
maintaining health, preventing disease and assisting
in the diagnosis and treatment of an injury, illness or
disability; drugs, biologicals and related preparations
as provided in Schedule B of the regulations, when
administered in the hospital; use of operating room,
case room and anaesthetic facilities, including necessary
equipment and supplies; routine surgical supplies; use
of radiotherapy facilities where available; use of physiotherapy facilities where available; and services rendered
by persons who receive remuneration therefore from the
hospital.
Section 2(f) of the regulations defines “outpatient
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 in-patient and out-patient services
provided in an approved hospital by hospital employees
are insured services. Standard nursing care, pharmaceuticals, supplies, diagnostic and operating services
are provided. Any new programs or enhancements
with significant funding implications or reductions to
services or programs require the prior approval of the
Minister, Health and Social Services. This process is
managed by the Director, Insured Health and Hearing
Services. Public representation regarding changes in
service levels is made through membership on the
hospital board.
Additional funds have been provided to Yukon to
assist patients with recourse options who have orthopaedic (knees and hip) or ophthalmology surgery
requirements.
These measures will help reduce Yukon’s reliance on
out-of-territory services.
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Chapter 3: Yukon
The territory is now administering 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 summer of 2010.
2.2Insured Physician Services
Sections 1 to 8 of the Health Care Insurance Plan Act
and sections 2, 3, 7, 10 and 13 of the Health Care
Insurance Plan Regulations provide for insured physician services. There were no amendments made to
these sections of the legislation in 2010–2011.
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 2010–2011 was 69.
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 2010–2011, 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
120
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.
In 2010–2011, new insured physician services included
the use of a portable ultrasound in the emergency room,
extended consultations for paediatrics, and specialist
services in physiatry.
2.3Insured Surgical-Dental Services
Dentists providing insured surgical-dental services
under the health care insurance plan of Yukon must
be licensed pursuant to the Dental Professions Act and
are given billing numbers to bill the Yukon Health Care
Insurance Plan for providing insured dental services.
The Plan is also billed directly for services provided
outside the territory.
Insured dental services are limited to those surgicaldental 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 2010–2011.
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
Canada Health Act — Annual Report 2010–2011
Chapter 3: Yukon
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 or
writing prescriptions; the supply of drugs; dental care
except procedures listed in Schedule B; and experimental
procedures.
Uninsured dental services include: procedures considered restorative; and procedures that are not
performed in a hospital under general anaesthesia.
All Yukon residents have equal access to services.
Third parties, such as private insurers or the Worker’s
Compensation Health and Safety Board, do not receive
priority access to services through additional payment.
The purchase of 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 noninsured 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; thirdparty 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:
Canada Health Act — Annual Report 2010–2011
• Physician services — the Yukon Health Care
Insurance Plan/Yukon Medical Association
Liaison Committee is responsible for reviewing changes to the Payment Schedule for Yukon,
including decisions to de-insure certain services. In
consultation with the Yukon Medical Advisor, decisions to de-insure services are based on medical
evidence that indicates the service is not medically
necessary, is ineffective or a potential risk to the
patient’s health. Once a decision has been made
to de-insure a service, all physicians are notified in
writing. The Director, Insured Health and Hearing
Services, manages this process. No services were
removed from the Payment Schedule for Yukon in
fiscal year 2010–2011.
• Hospital services — an amendment by OrderIn-Council to sections 2(e) and 2(f) of the Yukon
Hospital Insurance Services Regulations would
be required. As of March 31, 2011, no insured
in-patient or out-patient hospital services, as
provided for in the regulations, have been deinsured. The Director, Insured Health and Hearing
Services, is responsible for managing this process in conjunction with the Yukon Hospital
Corporation.
• Surgical-dental services — an amendment by
Order-In-Council to Schedule B of the Health Care
Insurance Plan Regulations is required. A service
could be de-insured if determined not medically
necessary or is no longer required to be carried
out in a hospital under general anaesthesia. The
Director, Insured Health and Hearing Services,
manages this process. No surgical-dental services
were de-insured in 2010–2011.
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 2010-2011. 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
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Chapter 3: Yukon
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;
• members of the Canadian Forces;
• convention refugees;
• members of the Royal Canadian Mounted
Police (RCMP);
• inmates in federal penitentiaries;
• study permit holders, unless they are a child and
they are listed as the dependent of a person who
holds a one year work permit; and
• employment authorizations of less than one year.
The above persons may become eligible for coverage if
they meet one or more of the following conditions:
• establish residency in Yukon;
• become a permanent resident; or
• For Canadian Forces members, RCMP members or
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, 2011 was 36,063.
3.2Other 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
122
• 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
4.1Minimum 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.
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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Yukon
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 2010–2011.
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.
4.3
Coverage During Temporary Absences
Outside Canada
The provisions that define portability of health care
insurance to insured persons during temporary absences
outside Canada are defined in sections 5, 6, 7, 9, 10 and
11 of the Yukon Health Care Insurance Plan Regulations
and sections 6, 7(1), 7(2) and 9 of the Yukon Hospital
Insurance Services Regulations.
No amendments were made to these sections of the
legislation in 2010–2011. Sections 5 and 6 state that,
“where an insured person is absent from Yukon and
Canada Health Act — Annual Report 2010–2011
intends to return, he is entitled to insured services
during a period of 12 months continuous absence.”
Persons leaving Yukon for a period exceeding three
months are advised to contact Yukon Health Care
Insurance Plan and complete a Temporary Absence
form. Failure to do so may result in cancellation of
the coverage.
The provisions for portability of health insurance during out-of-country absences for students, temporary
workers and missionaries are the same as for absences
within Canada (see section 4.2 of this report).
Insured physician services provided to eligible Yukon
residents temporarily outside the country are paid at
rates equivalent to those paid had the service been provided in Yukon. Reimbursement is made to the insured
person by the Yukon Health Care Insurance Plan or
directly to the provider of the insured service.
Insured in-patient hospital services provided to eligible
Yukon residents outside Canada are paid at the rate
established in the Standard Ward Rates Regulation for
the Whitehorse General Hospital.
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
5.1Access to Insured Health Services
There are no user fees or co-insurance charges under
the Yukon Health Care Insurance Plan or the Yukon
Hospital Insurance Services Plan. All services are
provided on a uniform basis and are not impeded by
financial or other barriers. There is no extra-billing
in the Yukon for any services covered by the Plan.
Access to hospital or physician services not available
locally are provided through the Visiting Specialist
Program, Telehealth Program or the Travel for Medical
Treatment Program. These programs ensure that
there is minimal or no delay in receiving medically
necessary services.
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Chapter 3: Yukon
To improve access to insured health services, the number of visiting specialists was increased to better serve
patients in the territory. A physiatrist was contracted
to provide services within our visiting specialist clinic.
The Department also increased the number of contract
physicians in communities to better serve the rural
population.
5.2
Physician Compensation
The Department of Health and Social Services seeks its
negotiating mandate from the Government of Yukon,
before entering into negotiations with the Yukon Medical
Association (YMA). The YMA and the government each
appoint members to the negotiating team. Meetings are
held as required until an agreement has been reached.
The YMA’s negotiating team then seeks approval of the
tentative agreement from the YMA membership. The
Department seeks ratification of the agreement from
the Government of Yukon. The final agreement is signed
with the concurrence of both parties.
The Memorandum of Understanding in effect for
the time period of this report came into effect on
April 1, 2008 and is ending on March 31, 2012. It
establishes the terms and conditions for payment
of physicians.
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 2010–2011.
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.
124
5.3
Payments to Hospitals
The Government of Yukon funds the Yukon Hospital
Corporation (Whitehorse General Hospital) through
global contribution agreements with the Department
of Health and Social Services. Global operations and
maintenance (O&M) and capital funding levels are
negotiated and adjusted based on operational requirements and utilization projections from prior years. In
addition to the established O&M and capital funding set
out in the agreement, provision is made for the hospital
to submit requests for additional funding assistance for
implementing new or enhanced programs.
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 2010–2011.
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 2010–2011 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 2010–2011
Chapter 3: Yukon
Registered Persons
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
33,103
33,423
33,983
35,084
36,063
1.Number as of March 31st (#).
Insured Hospital Services Within Own Province or Territory
Public Facilities 1
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
15
15
15
15
15
44,049,050
44,573,638
49,051,490
51,734,000
57,655,576
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
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 ($).
Private For-Profit Facilities
2
Insured Hospital Services Provided to residents in another province or territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
738
976
1,013
956
1,047
8,808,130
10,742,393
11,183,888
15,333,983
16,583,657
8,735
9,027
9,983
12,830
13,197
2,168,964
2,155,225
2,888,247
3,248,555
3,413,932
6.Total number of claims, in-patient (#).
7.Total payments, in-patient ($).
8.Total number of claims, out-patient (#).
9.Total payments, out-patient ($).
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11.Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
11
15
13
19
25
20,257
32,075
12,003
67,671
45,893
42
74
40
92
74
7,101
11,782
8,233
18,862
12,741
1. Public facilities are the 13 health centres (Beaver Creek, Destruction Bay, Carcross, Carmacks, Dawson, Faro, Haines Junction, Mayo, Old Crow, Pelly Crossing,
Ross River, Teslin and Whitehorse) and 2 hospitals (Whitehorse and Watson Lake).
2. Additional funds for 2010–2011 for the upgrade of the Watson Lake Hospital.
Canada Health Act — Annual Report 2010–2011
125
Chapter 3: Yukon
Insured Physician Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
66
67
67
69
69
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
17.Total payments for services provided
by physicians paid through all payment
methods ($).
13,788,028
16,342,282
19,139,117
20,781,850
21,549,640
18.Total payments for services provided by
physicians paid through fee-for-service ($). 3
13,308,761
14,127,399
16,294,365
17,719,117
17,701,880
14.Number of participating physicians (#).
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
39,669
38,512
45,744
50,893
54,007
2,139,805
1,977,052
2,297,501
3,008,828
3,185,612
Insured Physician Services Provided Outside Canada
21.Number of services (#).
not available
not available
not available
not available
not available
22.Total payments ($).
not available
not available
not available
not available
not available
Insured Surgical-Dental Services Within Own Province or Territory4
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
23.Number of participating dentists (#).
3
3
4
4
2
24.Number of services provided (#).
5
4
23
4
4
2,887
4,433
25,602
6,271
4,631
25.Total payments ($).
3. Includes Visiting Specialists, Member Reimbursements, Locum Doctors, and Optometrist testing paid through fee-for-service. Excludes services and costs provided
by alternative payment agreements.
4. Includes direct billings for insured surgical-dental services received outside the territory.
126
Canada Health Act — Annual Report 2010–2011
Chapter 3: Northwest Territories
• A renewal process is underway for the Extended
Health Benefits Program to ensure up to date and
accurate information for the administration of the
benefits of the Program.
• Preparation began for a new Umbrella Health
and Social Services Discipline Act. Several professions will be regulated under this Act. Existing
legislation that is very outdated could also be
modernized under this legislative model.
Northwest
Territories
Introduction
The Department of Health and Social Services (DHSS)
along with seven regional Health and Social Service
Authorities (HSSA) and the Tlicho Community Services
Agency (TCSA), plan, manage, deliver and evaluate a
full repertoire of health and social services at both the
community and facility level throughout the Northwest
Territories (NWT).
During the fiscal year the Department carried out the
following activities:
• The Medical Profession Act came into force in
April 2010 and provides an updated registration
process for physicians based on best practices.
It also modernized the discipline and conduct
provisions of the Act to make them consistent
with other legislation in the NWT and across
the country.
• Immunization Regulations under the Public Health
Act were drafted. These regulations will allow for the
development of a notifiable immunization registry
and will improve immunization surveillance and
coverage throughout the Northwest Territories.
• A new Health Information Act is under development.
This new Act will provide up-to-date health-specific
access, and protection of privacy provisions that will
apply to health 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. Requirements
for compliance and reporting will also be completed.
Canada Health Act — Annual Report 2010–2011
1.0 Public Administration
1.1Health Care Insurance Plan and
Public Authority
The NWT 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
with the NWT includes the Medical Care Act and the
HIHSSA.
1.2
Reporting Relationship
Reporting to the Minister, the Department, along with
seven regional Health and Social Service Authorities
(HSSA) and the Tlicho Community Services Agency
(TCSA), plan, manage, deliver and evaluate a full
repertoire of health and social services at both the
community and facility level throughout the NWT.
The Minister appoints the Director of Medical Insurance
who is responsible for administering the Medical
Care Act and its regulations. The Director reports to
the Minister any matters concerning the operational
status of the Medical Care Plan. The Minister, through
the Boards of Management, administers the Hospital
Insurance Plan.
The Hospital Insurance Plan is administered in each
HSSA by a Minister appointed Management Board. The
Boards manage, control and operate health and social
services within the current parameters, resources and
policies. The Boards are responsible to the Minister.
Board members serve for three years, with exception
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Chapter 3: Northwest Territories
of the chairperson whose term is indeterminate. 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.
The Director of Medical Insurance and the Boards
of Management are responsible to the Minister, as
per section 8(1)(b) of the Canada Health Act.
1.3Audit 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
Insured out-patient hospital services include:
• laboratory tests;
• diagnostic Imaging (including interpretations
when needed);
• physiotherapy, speech and language pathology
therapy and occupational therapy;
• minor medical and surgical procedures and
related supplies; and
• psychiatric and psychological services under
approved 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.
2.1Insured Hospital Services
2.2Insured Physician Services
Insured hospital services in the NWT are provided under
the Hospital Insurance and Health and Social Services
Administration Act.
The NWT Medical Care Act and the NWT Medical Care
Regulation 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, 2011,
there were approximately 286 physicians licensed in
the NWT.
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
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.
• detoxification at approved centers.
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Canada Health Act — Annual Report 2010–2011
Chapter 3: Northwest Territories
The Director of Medical Insurance is responsible to
recommend tariffs for services payable by the NWT
Medical Care Plan, though it is the Minister who ultimately determines if services will be added, altered
or deleted from insured physician services under the
authority of the following regulations:
• 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
• prescribing rates of fees and charges that may
be paid in respect of insured service rendered by
medical practitioners whether in or outside the
NWT, and the conditions under which fees and
charges are payable.
2.3Insured Surgical-Dental Services
Licensed oral surgeons may submit claims for insured
surgical-dental 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 osteopathy, naturo­
pathy, chiropractics. Physiotherapy, psychiatry
and psychological therapies are not covered if
delivered in a non-approved location.
Canada Health Act — Annual Report 2010–2011
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.
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.
3.0 Universality
3.1Eligibility
The 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.
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, 2011 there were 42,391 individuals
registered with the NWT health care plan.
No formal terms exist for clients to opt out of the NWT
Health Care Plan.
3.2Other Categories of Individuals
Holders of employment visas, student visas and, in
some cases, visitor visas are covered if they meet the
provisions of the Eligibility and Portability Agreement
and Guidelines for health care plan coverage.
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Chapter 3: Northwest Territories
4.0Portability
4.1Minimum Waiting Period
Waiting periods for persons moving to the NWT are
consistent with the Interprovincial Agreement on
Eligibility and Portability. The waiting period ends
the first day of the third month of residency for those
moving permanently to the NWT, or the first day of
the thirteenth month for those whose work term was
for one year and has been extended. Confirmation of
extension may be required.
4.2
Coverage During Temporary Absences
in Canada
Section 4(2) of the Medical Care Act provides NWT
residents with access to insured health coverage while
temporarily out of the NWT but still in Canada, 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 postsecondary 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 16 million
dollars per paid out for hospital in-patient and outpatient 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.
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.
130
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
5.1Access to Insured Health Services
The Medical Travel Program provides barrier free
access to necessary medical services for 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 with access to services not
offered in the NWT through contractual agreements
with southern health authorities.
Telehealth services increased accessibility to insured
health services throughout the territory. During the
2010–2011 fiscal year telehealth was provided to
38 facilities, up from 20 in the previous fiscal year.
Every community in the NWT now has access to
Telehealth. The only exception is 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.
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 2010–2011
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 and
the Boards of Management for each HSSA and the TCSA
dictate payments made to hospitals. Government budgets, resources and levels of services offered determine
the allocated amounts.
Payments to HSSA’s providing insured hospital services
are governed under the Hospital Insurance and Health
and Social Services Administration Act and the Financial
Administration Act. A comprehensive budget is used to
fund hospitals in the NWT.
Canada Health Act — Annual Report 2010–2011
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:
• 2010–2011 Budget Address;
• 2010–2011 Main Estimates;
• 2010–2011 Public Accounts;
• 2011–2012 Business Plan for the Department
of Health and Social Services;
• 2010–2011 Business Plan for the Department
of Finance; and
• 2009–2010 Health and Social Services Annual
Report.
The Main Estimates report (noted above) is presented
annually to the Legislative Assembly and represents the
government’s financial plan.
131
Chapter 3: Northwest Territories
Registered Persons
2006–2007
1.Number as of March 31st (#).
45,551
2007–2008
1
46,177
2008–2009
46,792
1
2009–2010
39,437
1
2010–2011
42,391
1
1
Insured Hospital Services Within Own Province or Territory
Public Facilities
2.Number (#).
3.Payments for insured health services ($).
Private For-Profit Facilities
4.Number of private for-profit facilities
providing insured health services (#).
5.Payments to private for-profit facilities
for insured health services ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
27
27
27
27
27
64,418,406
85,365,096
74,250,863
74,627,230
65,592,556
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
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 ($).
8.Total number of claims, out-patient (#).
9.Total payments, out-patient ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
1,051
1,198
1,174
1,100
1,039
11,429,716
12,824,618
13,157,987
12,253,180
13,479,545
11,935
11,915
12,354
11,580
9,856
2,692,568
2,742,122
3,574,434
3,476,252
3,285,248
Insured Hospital Services Provided Outside Canada
10.Total number of claims, in-patient (#).
11.Total payments, in-patient ($).
12.Total number of claims, out-patient (#).
13.Total payments, out-patient ($).
9
8
11
8
7
16,970
41,786
24,078
33,175
54,896
54
43
39
41
38
9,635
6,666
13,642
13,254
23,888
All data are subject to future revisions. 2010–2011 estimated based on claim data as of September 14, 2011.
1. The 2006–2007 figure is as of September 6, 2007, the 2007–2008 figure is as of September 5, 2008, the 2008–2009 figure is as of September 1, 2009, the 2009–2010
figure is as of September 8, 2010 and 2010–2011 figure is as of September 8, 2011.
132
Canada Health Act — Annual Report 2010–2011
Chapter 3: Northwest Territories
Insured Physician Services Within Own Province or Territory
2006–2007
14.Number of participating physicians (#).
262
2007–2008
2
286
2008–2009
2
274
2009–2010
280
2
2010–2011
286
2
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
31,586,887
34,266,756
35,773,222
37,644,355
37,545,653
1,696,823
1,791,633
1,929,745
1,871,213
1,693,618
17.Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($). 8
2
Insured Physician Services Provided to Residents in Another Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
48,797
45,412
44,180
31,838
32,121
3,630,179
4,118,883
4,216,528
4,027,481
4,670,419
19.Number of services (#).
20.Total payments ($).
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
90
95
113
117
97
4,142
9,051
6,230
6,883
8,510
Insured Surgical-Dental Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
23.Number of participating dentists (#).
not available
not available
not available
not available
not available
24.Number of services provided (#).
not available
not available
not available
not available
not available
25.Total payments ($).
not available
not available
not available
not available
not available
2. Estimate based on total active physicians for each fiscal year.
Canada Health Act — Annual Report 2010–2011
133
134
Canada Health Act — Annual Report 2010–2011
Chapter 3: Nunavut
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 33,2201
is approximately 84 percent Inuit, and almost 53 percent
of the population is under the age of 25 years.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.
The territorial operations and maintenance budget
for the Department of Health and Social Services in
2010–2011 was $291,020,000.5 Over 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 $18,269,000 was allocated to the
Department for capital projects.6
1.0 Public Administration
1.1Health Care Insurance Plan and
Public Authority
The health care insurance plans of Nunavut, including
physician and hospital services, are administered by
the Department 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 a regional office in each of the three
regions that manages 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 fiscal year
2010–2011.
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
1. Statistics Canada, Table 2 Quarterly demographic Estimates, http://www.statcan.gc.ca/daily-quotidien/100929/t100929b2-eng.htm
2. Statistics Canada, 2006 Census.
3. Government of Nunavut, 2010–2013 Business Plan.
4. Government of Nunavut, 2010–2013 Business Plan.
5. Public Accounts of the Government of Nunavut for the year ended March 31, 2010.
6. Public Accounts of the Government of Nunavut for the year ended March 31, 2010.
Canada Health Act — Annual Report 2010–2011
135
Chapter 3: Nunavut
the Nunavut Act. The Medical Care Act governs who is
covered by 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 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.
1.3Audit 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 March 30, 2011.
The Auditor General has the mandate to audit the activities of the Department. A report specific to the financial
management practices of the Department of Health and
Social Services was issued by the Office of the Auditor
General in 2009–2010. In June 2010, a report was tabled
in response to the Standing Committee on Oversight of
Government Operations and Public Accounts’ Report on
the Review of the 2009 Reports of the Auditor General
of Canada to the Legislative Assembly of Nunavut on
the Financial Management Practices of the Department
of Health and Social Services and the Follow-up on the
2005 Report to the Legislative Assembly of Nunavut on
the Financial Management Practices of the Government
of Nunavut.
2.0Comprehensiveness
2.1Insured 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 2010–2011.
In 2010–2011, 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.
136
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, paediatrics
and palliative care), surgical services, laboratory services, diagnostic imaging, respiratory therapy, and health
records and information. However, 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.
Community health centres provide public health services,
out-patient services and urgent treatment services. There
are also a limited number of birthing beds at the Rankin
Inlet Birthing Centre. Public health services are provided
at public health clinics located in Rankin Inlet and Iqaluit.
The Department also operates a Family Practice Clinic in
Iqaluit. The clinic, established in 2006 with funding from
the Primary Health Care Transition Fund, has been successful in helping to reduce pressure on the emergency
and out-patient departments of the QGH during working
hours. The clinic provides a steady source of primary
care appointments and programs, such as a Diabetes
Clinic, and receives physician support via 2–3 physician
days per month. At present, the clinic is staffed by three
nurse practitioners who provide approximately 41% of
all primary care visits in Iqaluit.
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 and psychological
services provided under an approved program; services
rendered by persons who are paid by the hospital; and
services rendered by an approved detoxification centre.
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
Canada Health Act — Annual Report 2010–2011
Chapter 3: Nunavut
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 2010–2011 to the list of insured
hospital services.
2.2Insured 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 2010–2011. 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 fulltime family physicians has improved significantly and
there are 25 family physician positions funded through
the Department, providing over 5,000 days of service
annually across the territory. In 2010–2011, all family
physician positions in Nunavut were staffed.
There are a total of 25 full-time physician positions in
Nunavut (14 in the Baffin region; 4.5 positions in the
Kivalliq region; 2.5 positions in the Kitikmeot region;
as well as 1 surgeon, 1 anaesthetist, 1 pediatrician
and 1 psychiatrist 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.
On March 31, 2011, Nunavut had 225 physicians participating in the health insurance plan.
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
2010–2011, no physicians provided written notice
of this election.
All physicians practising in Nunavut are under contract
with the Department.
Insured physician services refers to all services rendered
by medical practitioners that are medically required.
Where insured services are unavailable in some places
Canada Health Act — Annual Report 2010–2011
in Nunavut, the patient is referred to another jurisdiction to obtain the insured service. Nunavut has in place
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 2010–2011.
2.3Insured Surgical-Dental Services
Dentists providing insured surgical-dental services
under the Medical Care Insurance Plan of the territory
must be licensed pursuant to the Dental Professions
Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999). Billing numbers are
provided for billing the Plan regarding the provision of
insured dental services.
Insured dental services are limited to those dental-surgical
procedures scheduled in the regulations, requiring the
unique capabilities of a hospital for their performance;
for example, orthognathic surgery. Oral surgeons are
brought to Nunavut on a regular basis, but on rare occasions, for medically complicated situations, patients are
flown out of the territory.
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 2010–2011.
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
137
Chapter 3: Nunavut
therapy and psychology services received in a facility
that is not an insured out-patient facility (hospital).
confirm residency. Eligible residents receive a health
card with a unique health care number.
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.
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.
In 2010–2011 the Qikiqtani General Hospital charged
$2,046 per diem 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.
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 Inter­
provincial Agreement on Eligibility and Portability,
as well as internal guidelines. No amendments were
made to the Act or regulations in 2010–2011.
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
138
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-Canadian 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), 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, 2011, 35,515 individuals were registered
with the Nunavut Health Care Plan, up by 1,975 from the
previous year. There are no formal provisions for Nunavut
residents to opt out of the health care insurance plan.
3.2Other Categories of Individual
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, assessment is 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.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Nunavut
4.0Portability
4.1Minimum 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
2010–2011 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 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 person.
The provisions regarding coverage during temporary absences in Canada fully comply with the terms
and conditions of the Interprovincial Agreement on
Eligibility and Portability, as of January 1, 2001.
Nunavut participates in physician and hospital reciprocal billing. As well, special bilateral agreements are in
place with Ontario, Manitoba, Alberta and the Northwest
Territories. The Hospital Reciprocal Billing Agreements
provide payment of in- and out-patient hospital services
to eligible Nunavut residents receiving insured services
outside the territory. High-cost procedure rates, newborn rates and out-patient rates are based on those
established by the Interprovincial Health Insurance
Agreements Coordinating Committee. A special agreement exists between the Northwest Territories and
Canada Health Act — Annual Report 2010–2011
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 $2,046 per day and $260 for
out-patient care. These rates increased by $112 and
$22 respectively from 2009–2010.
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.
4.4
Prior Approval Requirement
Prior approval is required for elective services provided
in private facilities in Canada or in any facility outside
the country.
5.0Accessibility
5.1Access 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
139
Chapter 3: Nunavut
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. There are also 6 day
surgery beds and 4 recovery 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, basic services were provided
in 2010–2011.
Outside of Iqaluit, out-patient and 24-hour emergency
nursing services are provided by local health centres in
Nunavut’s 24 other communities. Telehealth services are
available in all 25 communities in Nunavut. The longterm goal is to integrate Telehealth into the primary care
delivery system, enabling residents of Nunavut greater
access to a broader range of service options, and allowing service providers and communities to use existing
resources more effectively.
Nunavut has agreements in place with a number of
out-of-territory 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 2010–2011
under the visiting specialists program: ophthalmology;
orthopaedics; internal medicine; otolaryngology; neurology; rheumatology; dermatology; paediatrics; obstetrics;
140
physiotherapy; occupational therapy; psychiatry; and oral
surgery. 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.
5.2
Physician Compensation
All full-time physicians in Nunavut work under contract
with the Department. The terms of the contracts are set
by the Department. Visiting consultants are either paid
on a per-diem basis or through fee-for-service.
5.3
Payments to Hospitals
Funding for the 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 2010–2011, they included:
• 2010–2011 Budget Address; and
• 2010–2011 Government of Nunavut Business Plan.
Canada Health Act — Annual Report 2010–2011
Chapter 3: Nunavut
Registered Persons
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
30,104
31,412
32,207
33,540
35,515
1.Number as of March 31st (#).
7
Insured Hospital Services Within Own Province or Territory
Public Facilities
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
28
28
28
28
28
not available
not available
not available
not available
not available
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
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 ($).
Private For-Profit Facilities
Insured Hospital Services Provided to residents in another province or territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
2,761
2,255
2,841
2,890
2,924
21,829,373
19,001,348
26,481,948
30,013,566
28,527,577
16,242
15,192
19,579
18,270
18,352
3,652,515
3,659,654
6,631,568
5,985,808
6,318,885
6.Total number of claims, in-patient (#).
7.Total payments, in-patient ($).
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 (#).
5
0
0
0
0
1,105
0
0
0
0
13.Total payments, out-patient ($).
7. The difference in the number of registered Nunavut residents and those covered under the Nunavut Health Care Plan is due to delays in the reconciliation of data on
residents who have left the territory.
Canada Health Act — Annual Report 2010–2011
141
Chapter 3: Nunavut
Insured Physician Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
127
156
218
225
225
15.Number of opted-out physicians (#).
0
0
0
0
0
16.Number of non-participating physicians (#).
0
0
0
0
0
not available
not available
not available
not available
not available
2,380,746
2,158,549
1,021,829
300,980
312,786
14.Number of participating physicians (#).
17.Total payments for services provided
by physicians paid through all payment
methods ($).
18.Total payments for services provided by
physicians paid through fee-for-service ($). 8
Insured Physician Services Provided to Residents in Another Province or Territory
19.Number of services (#).
20.Total payments ($).
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
59,121
53,022
65,171
72,065
73,564
3,623,163
3,845,570
4,768,388
5,585,067
5,901,962
Insured Physician Services Provided Outside Canada
21.Number of services (#).
22.Total payments ($).
5
15
36
17
53
1,105
796
2,458
4,848
1,575
Insured Surgical-Dental Services Within Own Province or Territory
2006–2007
2007–2008
2008–2009
2009–2010
2010–2011
23.Number of participating dentists (#).
not available
not available
not available
not available
not available
24.Number of services provided (#).
not available
not available
not available
not available
not available
25.Total payments ($).
not available
not available
not available
not available
not available
8. Typically, Nunavut does not pay its physicians through fee-for-service. Instead, the majority of physicians are compensated through contracted salaries. Statistical
information on salaried physicians is reported via the shadow billing process.
142
Canada Health Act — Annual Report 2010–2011
Annex A: Canada Health Act and the Extra-Billing and User Charges Information Regulations
Appendix A
CAnada Health Act and Extra-Billing
and User Charges Information
Regulations
This annex provides the reader with an office consolidation of the Canada Health Act and the Extra-billing
and User Charges Information Regulations. An “office
consolidation” is a rendering of the original Act, which
includes any amendments that have been made since
the Act’s passage. The only regulations in force under
the Act are the Extra-billing and User Charges Information Regulations. These regulations require the
provinces and territories to provide estimates of extrabilling and user charges prior to the beginning of
Canada Health Act — Annual Report 2010–2011
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
October 2009. It is provided for the convenience of the
reader only. For the official text of the Canada Health
Act, please contact Justice Canada.
143
144
Canada Health Act — Annual Report 2010–2011
CANADA
CANADA
CONSOLIDATION
CODIFICATION
Canada Health Act
Loi canadienne sur la
santé
CHAPTER C-6
CHAPITRE C-6
Current to July 11, 2010
À jour au 11 juillet 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://laws-lois.justice.gc.ca
Canada Health Act — Annual Report 2010–2011
145
Published
consolidation is
evidence
Inconsistencies
in Acts
146
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.
Codifications
comme élément
de preuve
Incompatibilité
— lois
Canada Health Act — Annual Report 2010–2011
Preamble
CHAPTER C-6
CHAPITRE C-6
An Act relating to cash contributions by
Canada and relating to criteria and
conditions in respect of insured health
services and extended health care services
Loi concernant les contributions pécuniaires du
Canada ainsi que les principes et
conditions applicables aux services de
santé
assurés
et
aux
services
complémentaires de santé
WHEREAS the Parliament of Canada recognizes:
Considérant que le Parlement du Canada
reconnaît :
—that it is not the intention of the Government of Canada that any of the powers,
rights, privileges or authorities vested in
Canada or the provinces under the provisions
of the Constitution Act, 1867, or any amendments thereto, or otherwise, be by reason of
this Act abrogated or derogated from or in
any way impaired;
que le gouvernement du Canada n’entend
pas par la présente loi abroger les pouvoirs,
droits, privilèges ou autorités dévolus au
Canada ou aux provinces sous le régime de
la Loi constitutionnelle de 1867 et de ses modifications ou à tout autre titre, ni leur déroger ou porter atteinte,
—that Canadians, through their system of insured health services, have made outstanding
progress in treating sickness and alleviating
the consequences of disease and disability
among all income groups;
que les Canadiens ont fait des progrès remarquables, grâce à leur système de services de
santé assurés, dans le traitement des maladies
et le soulagement des affections et déficiences parmi toutes les catégories socioéconomiques,
—that Canadians can achieve further improvements in their well-being through combining individual lifestyles that emphasize
fitness, prevention of disease and health promotion with collective action against the social, environmental and occupational causes
of disease, and that they desire a system of
health services that will promote physical
and mental health and protection against disease;
que les Canadiens peuvent encore améliorer
leur bien-être en joignant à un mode de vie
individuel axé sur la condition physique, la
prévention des maladies et la promotion de la
santé, une action collective contre les causes
sociales, environnementales ou industrielles
des maladies et qu’ils désirent un système de
services de santé qui favorise la santé physique et mentale et la protection contre les
maladies,
—that future improvements in health will require the cooperative partnership of governments, health professionals, voluntary organizations and individual Canadians;
que les améliorations futures dans le domaine de la santé nécessiteront la coopération des gouvernements, des professionnels
de la santé, des organismes bénévoles et des
citoyens canadiens,
—that continued access to quality health care
without financial or other barriers will be
critical to maintaining and improving the
health and well-being of Canadians;
Préambule
que l’accès continu à des soins de santé de
qualité, sans obstacle financier ou autre, sera
déterminant pour la conservation et l’amélioration de la santé et du bien-être des Canadiens;
1
Canada Health Act — Annual Report 2010–2011
147
Canada Health — July 11, 2010
Short title
AND WHEREAS the Parliament of Canada
wishes to encourage the development of health
services throughout Canada by assisting the
provinces in meeting the costs thereof;
considérant en outre que le Parlement du
Canada souhaite favoriser le développement
des services de santé dans tout le pays en aidant
les provinces à en supporter le coût,
NOW, THEREFORE, Her Majesty, by and
with the advice and consent of the Senate and
House of Commons of Canada, enacts as follows:
Sa Majesté, sur l’avis et avec le consentement
du Sénat et de la Chambre des communes du
Canada, édicte :
SHORT TITLE
TITRE ABRÉGÉ
1. This Act may be cited as the Canada
Health Act.
1. Loi canadienne sur la santé.
Titre abrégé
1984, ch. 6, art. 1.
1984, c. 6, s. 1.
INTERPRETATION
Definitions
DÉFINITIONS
2. In this Act,
“Act of 1977” [Repealed, 1995, c. 17, s. 34]
“cash
contribution”
« contribution
pécuniaire »
“cash contribution” means the cash contribution in respect of the Canada Health and Social
Transfer that may be provided to a province under subsections 15(1) and (4) of the FederalProvincial Fiscal Arrangements Act;
“dentist” means a person lawfully entitled to
practise dentistry in the place in which the
practice is carried on by that person;
“extended health
care services”
« services
complémentaires
de santé »
“extended health care services” means the following services, as more particularly defined in
the regulations, provided for residents of a
province, namely,
148
« assuré »
“insured
person”
d’une
province,
à
c) des personnes purgeant une peine d’emprisonnement dans un pénitencier, au sens de
la Partie I de la Loi sur le système correctionnel et la mise en liberté sous condition;
d) des habitants de la province qui s’y
trouvent depuis une période de temps inférieure au délai minimal de résidence ou de
carence d’au plus trois mois imposé aux habitants par la province pour qu’ils soient admissibles ou aient droit aux services de santé
assurés.
(b) adult residential care service,
“health care
insurance plan”
« régime
d’assurancesanté »
« assuré » Habitant
l’exception :
b) des membres de la Gendarmerie royale
du Canada nommés à un grade;
(a) nursing home intermediate care service,
“extra-billing”
« surfacturation »
Définitions
a) des membres des Forces canadiennes;
“contribution” [Repealed, 1995, c. 17, s. 34]
“dentist”
« dentiste »
2. Les définitions qui suivent s’appliquent à
la présente loi.
(c) home care service, and
« contribution » [Abrogée, 1995, ch. 17, art. 34]
(d) ambulatory health care service;
« contribution pécuniaire » La contribution au
titre du Transfert canadien en matière de santé
et de programmes sociaux qui peut être versée
à une province au titre des paragraphes 15(1) et
(4) de la Loi sur les arrangements fiscaux entre
le gouvernement fédéral et les provinces.
« contribution
pécuniaire »
“cash
contribution”
« dentiste » Personne légalement autorisée à
exercer la médecine dentaire au lieu où elle se
livre à cet exercice.
« dentiste »
“dentist”
« frais modérateurs » Frais d’un service de santé
assuré autorisés ou permis par un régime pro-
« frais
modérateurs »
“user charge”
“extra-billing” means the billing for an insured
health service rendered to an insured person by
a medical practitioner or a dentist in an amount
in addition to any amount paid or to be paid for
that service by the health care insurance plan of
a province;
“health care insurance plan” means, in relation
to a province, a plan or plans established by the
law of the province to provide for insured
health services;
2
Canada Health Act — Annual Report 2010–2011
Santé — 11 juillet 2010
“health care
practitioner”
« professionnel
de la santé »
“health care practitioner” means a person lawfully entitled under the law of a province to
provide health services in the place in which
the services are provided by that person;
“hospital”
« hôpital »
“hospital” includes any facility or portion
thereof that provides hospital care, including
acute, rehabilitative or chronic care, but does
not include
vincial d’assurance-santé mais non payables,
soit directement soit indirectement, au titre
d’un régime provincial d’assurance-santé, à
l’exception des frais imposés par surfacturation.
(a) a hospital or institution primarily for the
mentally disordered, or
(b) a facility or portion thereof that provides
nursing home intermediate care service or
adult residential care service, or comparable
services for children;
“hospital
services”
« services
hospitaliers »
“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,
« hôpital » Sont compris parmi les hôpitaux tout
ou partie des établissements où sont fournis des
soins hospitaliers, notamment aux personnes
souffrant de maladie aiguë ou chronique ainsi
qu’en matière de réadaptation, à l’exception :
« hôpital »
“hospital”
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,
(c) laboratory, radiological and other diagnostic procedures, together with the necessary interpretations,
(d) drugs, biologicals and related preparations when administered in the hospital,
(e) use of operating room, case room and
anaesthetic facilities, including necessary
equipment and supplies,
(f) medical and surgical equipment and supplies,
(g) use of radiotherapy facilities,
(h) use of physiotherapy facilities, and
(i) services provided by persons who receive
remuneration therefor from the hospital,
but does not include services that are excluded
by the regulations;
« médecin » Personne légalement autorisée à
exercer la médecine au lieu où elle se livre à cet
exercice.
« médecin »
“medical
practitioner”
« ministre » Le ministre de la Santé.
« ministre »
“Minister”
« professionnel de la santé » Personne légalement autorisée en vertu de la loi d’une province
à fournir des services de santé au lieu où elle
les fournit.
« professionnel
de la santé »
“health care
practitioner”
« régime d’assurance-santé » Le régime ou les
régimes constitués par la loi d’une province en
vue de la prestation de services de santé assurés.
« régime
d’assurancesanté »
“health care
insurance plan”
« services complémentaires de santé » Les services définis dans les règlements et offerts aux
habitants d’une province, à savoir :
« services
complémentaires
de santé »
“extended health
care services”
a) les soins intermédiaires en maison de repos;
“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 2010–2011
« habitant »
“resident”
a) des hôpitaux ou institutions destinés principalement aux personnes souffrant de
troubles mentaux;
(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 » 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.
b) les soins en établissement pour adultes;
c) les soins à domicile;
d) les soins ambulatoires.
3
149
Canada Health — July 11, 2010
ture of a province that relates to workers' or
workmen’s compensation;
“insured person”
« assuré »
“insured person” means, in relation to a
province, a resident of the province other than
(a) a member of the Canadian Forces,
(b) a member of the Royal Canadian Mounted Police who is appointed to a rank therein,
(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;
« services de chirurgie dentaire » Actes de chirurgie dentaire nécessaires sur le plan médical
ou dentaire, accomplis par un dentiste dans un
hôpital, et qui ne peuvent être accomplis convenablement qu’en un tel établissement.
« services de
chirurgie
dentaire »
“surgical-dental
services”
« services de santé assurés » Services hospitaliers, médicaux ou de chirurgie dentaire fournis
aux assurés, à l’exception des services de santé
auxquels une personne a droit ou est admissible
en vertu d’une autre loi fédérale ou d’une loi
provinciale relative aux accidents du travail.
« services de
santé assurés »
“insured health
services”
« services hospitaliers » Services fournis dans
un hôpital aux malades hospitalisés ou externes, si ces services sont médicalement nécessaires pour le maintien de la santé, la prévention des maladies ou le diagnostic ou le
traitement des blessures, maladies ou invalidités, à savoir :
« services
hospitaliers »
“hospital
services”
“medical
practitioner”
« médecin »
“medical practitioner” means a person lawfully
entitled to practise medicine in the place in
which the practice is carried on by that person;
“Minister”
« ministre »
“Minister” means the Minister of Health;
“physician
services”
« services
médicaux »
“physician services” means any medically required services rendered by medical practitioners;
c) les actes de laboratoires, de radiologie ou
autres actes de diagnostic, ainsi que les interprétations nécessaires;
“resident”
« habitant »
“resident” means, in relation to a province, a
person lawfully entitled to be or to remain in
Canada who makes his home and is ordinarily
present in the province, but does not include a
tourist, a transient or a visitor to the province;
d) les produits pharmaceutiques, substances
biologiques et préparations connexes administrés à l’hôpital;
“surgical-dental
services”
« services de
chirurgie
dentaire »
“surgical-dental services” means any medically
or dentally required surgical-dental procedures
performed by a dentist in a hospital, where a
hospital is required for the proper performance
of the procedures;
“user charge”
« frais
modérateurs »
“user charge” means any charge for an insured
health service that is authorized or permitted by
a provincial health care insurance plan that is
not payable, directly or indirectly, by a provincial health care insurance plan, but does not include any charge imposed by extra-billing.
a) l’hébergement et la fourniture des repas
en salle commune ou, si médicalement nécessaire, en chambre privée ou semi-privée;
b) les services infirmiers;
e) l’usage des salles d’opération, des salles
d’accouchement et des installations d’anesthésie, ainsi que le matériel et les fournitures
nécessaires;
f) le matériel et les fournitures médicaux et
chirurgicaux;
g) l’usage des installations de radiothérapie;
h) l’usage des installations de physiothérapie;
i) les services fournis par les personnes rémunérées à cet effet par l’hôpital.
Ne sont pas compris parmi les services hospitaliers les services exclus par les règlements.
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.
150
4
« services médicaux » Services médicalement
nécessaires fournis par un médecin.
« services
médicaux »
“physician
services”
« surfacturation » Facturation de la prestation à
un assuré par un médecin ou un dentiste d’un
service de santé assuré, en excédent par rapport
« surfacturation »
“extra-billing”
Canada Health Act — Annual Report 2010–2011
Santé — 11 juillet 2010
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.
Primary
objective of
Canadian health
care policy
Purpose of this
Act
CANADIAN HEALTH CARE POLICY
POLITIQUE CANADIENNE DE LA SANTÉ
3. It is hereby declared that the primary objective of Canadian health care policy is to protect, promote and restore the physical and mental well-being of residents of Canada and to
facilitate reasonable access to health services
without financial or other barriers.
3. La politique canadienne de la santé a pour
premier objectif de protéger, de favoriser et
d’améliorer le bien-être physique et mental des
habitants du Canada et de faciliter un accès satisfaisant aux services de santé, sans obstacles
d’ordre financier ou autre.
1984, c. 6, s. 3.
1984, ch. 6, art. 3.
PURPOSE
RAISON D’ÊTRE
4. The purpose of this Act is to establish criteria and conditions in respect of insured health
services and extended health care services provided under provincial law that must be met before a full cash contribution may be made.
4. La présente loi a pour raison d’être d’établir les conditions d’octroi et de versement
d’une pleine contribution pécuniaire pour les
services de santé assurés et les services complémentaires de santé fournis en vertu de la loi
d’une province.
R.S., 1985, c. C-6, s. 4; 1995, c. 17, s. 35.
Objectif premier
Raison d’être de
la présente loi
L.R. (1985), ch. C-6, art. 4; 1995, ch. 17, art. 35.
Cash
contribution
CASH CONTRIBUTION
CONTRIBUTION PÉCUNIAIRE
5. Subject to this Act, as part of the Canada
Health and Social 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 et de programmes
sociaux (ci-après, Transfert).
R.S., 1985, c. C-6, s. 5; 1995, c. 17, s. 36.
Contribution
pécuniaire
L.R. (1985), ch. C-6, art. 5; 1995, ch. 17, art. 36.
6. [Repealed, 1995, c. 17, s. 36]
Program criteria
6. [Abrogé, 1995, ch. 17, art. 36]
PROGRAM CRITERIA
CONDITIONS D’OCTROI
7. In order that a province may qualify for a
full cash contribution referred to in section 5
for a fiscal year, the health care insurance plan
of the province must, throughout the fiscal
year, satisfy the criteria described in sections 8
to 12 respecting the following matters:
7. Le versement à une province, pour un
exercice, de la pleine contribution pécuniaire
visée à l’article 5 est assujetti à l’obligation
pour le régime d’assurance-santé de satisfaire,
pendant tout cet exercice, aux conditions d’octroi énumérées aux articles 8 à 12 quant à :
(a) public administration;
a) la gestion publique;
(b) comprehensiveness;
b) l’intégralité;
(c) universality;
c) l’universalité;
(d) portability; and
d) la transférabilité;
e) l’accessibilité.
(e) accessibility.
1984, c. 6, s. 7.
Canada Health Act — Annual Report 2010–2011
Règle générale
1984, ch. 6, art. 7.
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Canada Health — July 11, 2010
Public
administration
8. (1) In order to satisfy the criterion respecting public administration,
8. (1) La condition de gestion publique suppose que :
(a) the health care insurance plan of a
province must be administered and operated
on a non-profit basis by a public authority
appointed or designated by the government
of the province;
a) le régime provincial d’assurance-santé
soit géré sans but lucratif par une autorité publique nommée ou désignée par le gouvernement de la province;
b) l’autorité publique soit responsable devant le gouvernement provincial de cette
gestion;
(b) the public authority must be responsible
to the provincial government for that administration and operation; and
c) l’autorité publique soit assujettie à la vérification de ses comptes et de ses opérations
financières par l’autorité chargée par la loi de
la vérification des comptes de la province.
(c) the public authority must be subject to
audit of its accounts and financial transactions by such authority as is charged by law
with the audit of the accounts of the
province.
Designation of
agency
permitted
Comprehensiveness
Gestion
publique
(2) The criterion respecting public administration is not contravened by reason only that
the public authority referred to in subsection (1)
has the power to designate any agency
(2) La condition de gestion publique n’est
pas enfreinte du seul fait que l’autorité publique
visée au paragraphe (1) a le pouvoir de désigner un mandataire chargé :
(a) to receive on its behalf any amounts
payable under the provincial health care insurance plan; or
a) soit de recevoir en son nom les montants
payables au titre du régime provincial d’assurance-santé;
(b) to carry out on its behalf any responsibility in connection with the receipt or payment
of accounts rendered for insured health services, if it is a condition of the designation
that all those accounts are subject to assessment and approval by the public authority
and that the public authority shall determine
the amounts to be paid in respect thereof.
b) soit d’exercer en son nom les attributions
liées à la réception ou au règlement des
comptes remis pour prestation de services de
santé assurés si la désignation est assujettie à
la vérification et à l’approbation par l’autorité publique des comptes ainsi remis et à la
détermination par celle-ci des montants à
payer à cet égard.
1984, c. 6, s. 8.
1984, ch. 6, art. 8.
9. In order to satisfy the criterion respecting
comprehensiveness, the health care insurance
plan of a province must insure all insured
health services provided by hospitals, medical
practitioners or dentists, and where the law of
the province so permits, similar or additional
services rendered by other health care practitioners.
9. La condition d’intégralité suppose qu’au
titre du régime provincial d’assurance-santé,
tous les services de santé assurés fournis par les
hôpitaux, les médecins ou les dentistes soient
assurés, et lorsque la loi de la province le permet, les services semblables ou additionnels
fournis par les autres professionnels de la santé.
Désignation
d’un mandataire
Intégralité
1984, ch. 6, art. 9.
1984, c. 6, s. 9.
Universality
10. In order to satisfy the criterion respecting universality, the health care insurance plan
of a province must entitle one hundred per cent
of the insured persons of the province to the insured health services provided for by the plan
on uniform terms and conditions.
10. La condition d’universalité suppose
qu’au titre du régime provincial d’assurancesanté, cent pour cent des assurés de la province
ait droit aux services de santé assurés prévus
par celui-ci, selon des modalités uniformes.
Universalité
1984, ch. 6, art. 10.
1984, c. 6, s. 10.
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Canada Health Act — Annual Report 2010–2011
Santé — 11 juillet 2010
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 insured health services provided to a resident of
the province while temporarily absent from the
province if the services in question were avail-
Canada Health Act — Annual Report 2010–2011
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
santé assurés facultatifs à un habitant temporairement absent de la province, si ces services y
sont offerts selon des modalités sensiblement
comparables.
7
Consentement
préalable à la
prestation des
services de santé
assurés
facultatifs
153
Canada Health — July 11, 2010
able on a substantially similar basis in the
province.
Definition of
"elective insured
health services"
Accessibility
(3) For the purpose of subsection (2), “elective insured health services” means insured
health services other than services that are provided in an emergency or in any other circumstance in which medical care is required without delay.
(3) Pour l’application du paragraphe (2),
« services de santé assurés facultatifs » s’entend
des services de santé assurés, à l’exception de
ceux qui sont fournis d’urgence ou dans
d’autres circonstances où des soins médicaux
sont requis sans délai.
1984, c. 6, s. 11.
1984, ch. 6, art. 11.
12. (1) In order to satisfy the criterion respecting accessibility, the health care insurance
plan of a province
12. (1) La condition d’accessibilité suppose
que le régime provincial d’assurance-santé :
b) prévoie la prise en charge des services de
santé assurés selon un tarif ou autre mode de
paiement autorisé par la loi de la province;
(b) must provide for payment for insured
health services in accordance with a tariff or
system of payment authorized by the law of
the province;
c) prévoie une rémunération raisonnable de
tous les services de santé assurés fournis par
les médecins ou les dentistes;
d) prévoie le versement de montants aux hôpitaux, y compris les hôpitaux que possède
ou gère le Canada, à l’égard du coût des services de santé assurés.
(c) must provide for reasonable compensation for all insured health services rendered
by medical practitioners or dentists; and
(d) must provide for the payment of
amounts to hospitals, including hospitals
owned or operated by Canada, in respect of
the cost of insured health services.
(2) 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 :
(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
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 organisations provinciales et la province et
ayant un président indépendant;
(b) for the settlement of disputes relating to
compensation through, at the option of the
appropriate provincial organizations referred
to in paragraph (a), conciliation or binding
arbitration by a panel that is equally representative of the provincial organizations and
154
Accessibilité
a) offre les services de santé assurés selon
des modalités uniformes et ne fasse pas obstacle, directement ou indirectement, et notamment par facturation aux assurés, à un accès satisfaisant par eux à ces services;
(a) must provide for insured health services
on uniform terms and conditions and on a
basis that does not impede or preclude, either
directly or indirectly whether by charges
made to insured persons or otherwise, reasonable access to those services by insured
persons;
Reasonable
compensation
Définition de
« services de
santé assurés
facultatifs »
8
Canada Health Act — Annual Report 2010–2011
Santé — 11 juillet 2010
c) l’impossibilité de modifier la décision du
groupe visé à l’alinéa b), sauf par une loi de
la province.
the province and that has an independent
chairman; and
(c) that a decision of a panel referred to in
paragraph (b) may not be altered except by
an Act of the legislature of the province.
1984, ch. 6, art. 12.
1984, c. 6, s. 12.
Conditions
CONDITIONS FOR CASH CONTRIBUTION
CONTRIBUTION PÉCUNIAIRE
ASSUJETTIE À DES CONDITIONS
13. In order that a province may qualify for
a full cash contribution referred to in section 5,
the government of the province
13. Le versement à une province de la pleine
contribution pécuniaire visée à l’article 5 est assujetti à l’obligation pour le gouvernement de
la province :
(a) shall, at the times and in the manner prescribed by the regulations, provide the Minister with such information, of a type prescribed by the regulations, as the Minister
may reasonably require for the purposes of
this Act; and
Obligations de la
province
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 and Social Transfer in any public
documents, or in any advertising or promotional material, relating to insured health services and extended health care services in the
province.
b) de faire état du Transfert dans tout document public ou toute publicité sur les services de santé assurés et les services complémentaires de santé dans la province.
L.R. (1985), ch. C-6, art. 13; 1995, ch. 17, art. 37.
R.S., 1985, c. C-6, s. 13; 1995, c. 17, s. 37.
Referral to
Governor in
Council
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;
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
(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 :
(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;
Canada Health Act — Annual Report 2010–2011
Renvoi au
gouverneur en
conseil
Étapes de la
consultation
a) envoie par courrier recommandé à son
homologue chargé de la santé dans la province un avis sur tout problème éventuel;
9
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Canada Health — July 11, 2010
Where no
consultation can
be achieved
(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
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;
(c) if requested by the province, meet within
a reasonable period of time to discuss the report.
c) si la province le lui demande, tient une
réunion dans un délai acceptable afin de discuter du rapport.
(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.
(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, c. 6, s. 14.
Impossibilité de
consultation
1984, ch. 6, art. 14.
Order reducing
or withholding
contribution
15. (1) Where, on the referral of a matter
under section 14, the Governor in Council is of
the opinion that the health care insurance plan
of a province does not or has ceased to satisfy
any one of the criteria described in sections 8 to
12 or that a province has failed to comply with
any condition set out in section 13, the Governor in Council may, by order,
15. (1) Si l’affaire lui est renvoyée en vertu
de l’article 14 et qu’il estime que le régime
d’assurance-santé de la province ne satisfait pas
ou plus aux conditions visées aux articles 8 à
12 ou que la province ne s’est pas conformée
aux conditions visées à l’article 13, le gouverneur en conseil peut, par décret :
Décret de
réduction ou de
retenue
a) soit ordonner, pour chaque manquement,
que la contribution pécuniaire d’un exercice
à la province soit réduite du montant qu’il
estime indiqué, compte tenu de la gravité du
manquement;
(a) direct that any cash contribution to that
province for a fiscal year be reduced, in respect of each default, by an amount that the
Governor in Council considers to be appropriate, having regard to the gravity of the default; or
b) soit, s’il l’estime indiqué, ordonner la retenue de la totalité de la contribution pécuniaire d’un exercice à la province.
(b) where the Governor in Council considers
it appropriate, direct that the whole of any
cash contribution to that province for a fiscal
year be withheld.
Amending
orders
(2) The Governor in Council may, by order,
repeal or amend any order made under subsection (1) where the Governor in Council is of the
opinion that the repeal or amendment is warranted in the circumstances.
(2) Le gouverneur en conseil peut, par décret, annuler ou modifier un décret pris en vertu
du paragraphe (1) s’il l’estime justifié dans les
circonstances.
Modification des
décrets
Notice of order
(3) A copy of each order made under this
section together with a statement of any findings on which the order was based shall be sent
forthwith by registered mail to the government
of the province concerned and the Minister
shall cause the order and statement to be laid
before each House of Parliament on any of the
first fifteen days on which that House is sitting
after the order is made.
(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
les quinze premiers jours de séance de celle-ci
suivant la prise du décret.
Avis
Commencement
of order
(4) An order made under subsection (1)
shall not come into force earlier than thirty
(4) Un décret pris en vertu du paragraphe (1)
ne peut entrer en vigueur que trente jours après
Entrée en
vigueur du
décret
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Canada Health Act — Annual Report 2010–2011
Santé — 11 juillet 2010
Reimposition of
reductions or
withholdings
When reduction
or withholding
imposed
Extra-billing
days after a copy of the order has been sent to
the government of the province concerned under subsection (3).
l’envoi au gouvernement de la province concernée du texte du décret aux termes du paragraphe (3).
R.S., 1985, c. C-6, s. 15; 1995, c. 17, s. 38.
L.R. (1985), ch. C-6, art. 15; 1995, ch. 17, art. 38.
16. In the case of a continuing failure to satisfy any of the criteria described in sections 8 to
12 or to comply with any condition set out in
section 13, any reduction or withholding under
section 15 of a cash contribution to a province
for a fiscal year shall be reimposed for each
succeeding fiscal year as long as the Minister is
satisfied, after consultation with the minister responsible for health care in the province, that
the default is continuing.
16. En cas de manquement continu aux
conditions visées aux articles 8 à 12 ou à l’article 13, les réductions ou retenues de la contribution pécuniaire à une province déjà appliquées pour un exercice en vertu de l’article 15
lui sont appliquées de nouveau pour chaque
exercice ultérieur où le ministre estime, après
consultation de son homologue chargé de la
santé dans la province, que le manquement se
continue.
R.S., 1985, c. C-6, s. 16; 1995, c. 17, s. 39.
L.R. (1985), ch. C-6, art. 16; 1995, ch. 17, art. 39.
17. Any reduction or withholding under section 15 or 16 of a cash contribution may be imposed in the fiscal year in which the default that
gave rise to the reduction or withholding occurred or in the following fiscal year.
17. Toute réduction ou retenue d’une contribution pécuniaire visée aux articles 15 ou 16
peut être appliquée pour l’exercice où le manquement à son origine a eu lieu ou pour l’exercice suivant.
R.S., 1985, c. C-6, s. 17; 1995, c. 17, s. 39.
L.R. (1985), ch. C-6, art. 17; 1995, ch. 17, art. 39.
EXTRA-BILLING AND USER CHARGES
SURFACTURATION ET FRAIS
MODÉRATEURS
18. In order that a province may qualify for
a full cash contribution referred to in section 5
for a fiscal year, no payments may be permitted
by the province for that fiscal year under the
health care insurance plan of the province in respect of insured health services that have been
subject to extra-billing by medical practitioners
or dentists.
18. Une province n’a droit, pour un exercice, à la pleine contribution pécuniaire visée à
l’article 5 que si, aux termes de son régime
d’assurance-santé, elle ne permet pas pour cet
exercice le versement de montants à l’égard des
services de santé assurés qui ont fait l’objet de
surfacturation par les médecins ou les dentistes.
Nouvelle
application des
réductions ou
retenues
Application aux
exercices
ultérieurs
Surfacturation
1984, ch. 6, art. 18.
1984, c. 6, s. 18.
User charges
19. (1) In order that a province may qualify
for a full cash contribution referred to in section 5 for a fiscal year, user charges must not be
permitted by the province for that fiscal year
under the health care insurance plan of the
province.
19. (1) Une province n’a droit, pour un
exercice, à la pleine contribution pécuniaire visée à l’article 5 que si, aux termes de son régime d’assurance-santé, elle ne permet pour cet
exercice l’imposition d’aucuns frais modérateurs.
Frais
modérateurs
Limitation
(2) Subsection (1) does not apply in respect
of user charges for accommodation or meals
provided to an in-patient who, in the opinion of
the attending physician, requires chronic care
and is more or less permanently resident in a
hospital or other institution.
(2) Le paragraphe (1) ne s’applique pas aux
frais modérateurs imposés pour l’hébergement
ou les repas fournis à une personne hospitalisée
qui, de l’avis du médecin traitant, souffre d’une
maladie chronique et séjourne de façon plus ou
moins permanente à l’hôpital ou dans une autre
institution.
Réserve
1984, c. 6, s. 19.
1984, ch. 6, art. 19.
Deduction for
extra-billing
20. (1) Where a province fails to comply
with the condition set out in section 18, there
shall be deducted from the cash contribution to
Canada Health Act — Annual Report 2010–2011
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
11
Déduction en
cas de
surfacturation
157
Canada Health — July 11, 2010
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.
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.
Deduction for
user charges
(2) Where a province fails to comply with
the condition set out in section 19, there shall
be deducted from the cash contribution to the
province for a fiscal year an amount that the
Minister, on the basis of information provided
in accordance with the regulations, determines
to have been charged in the province in respect
of user charges to which section 19 applies in
that fiscal year or, where information is not
provided in accordance with the regulations, an
amount that the Minister estimates to have been
so charged.
(2) Dans le cas où une province ne se
conforme pas à la condition visée à l’article 19,
il est déduit de la contribution pécuniaire à
cette dernière pour un exercice un montant, déterminé par le ministre d’après les renseignements fournis conformément aux règlements,
égal au total des frais modérateurs assujettis à
l’article 19 imposés dans la province pendant
l’exercice ou, si les renseignements n’ont pas
été fournis conformément aux règlements, un
montant estimé par le ministre égal à ce total.
Déduction en
cas de frais
modérateurs
Consultation
with province
(3) The Minister shall not estimate an
amount under subsection (1) or (2) without first
undertaking to consult the minister responsible
for health care in the province concerned.
(3) Avant d’estimer un montant visé au paragraphe (1) ou (2), le ministre se charge de
consulter son homologue responsable de la santé dans la province concernée.
Consultation de
la province
Separate
accounting in
Public Accounts
(4) Any amount deducted under subsection
(1) or (2) from a cash contribution in any of the
three consecutive fiscal years the first of which
commences on April 1, 1984 shall be accounted for separately in respect of each province in
the Public Accounts for each of those fiscal
years in and after which the amount is deducted.
(4) Les montants déduits d’une contribution
pécuniaire en vertu des paragraphes (1) ou (2)
pendant les trois exercices consécutifs dont le
premier commence le 1er avril 1984 sont comptabilisés séparément pour chaque province dans
les comptes publics pour chacun de ces exercices pendant et après lequel le montant a été
déduit.
Comptabilisation
Refund to
province
(5) Where, in any of the three fiscal years
referred to in subsection (4), extra-billing or user charges have, in the opinion of the Minister,
been eliminated in a province, the total amount
deducted in respect of extra-billing or user
charges, as the case may be, shall be paid to the
province.
(5) Si, de l’avis du ministre, la surfacturation ou les frais modérateurs ont été supprimés
dans une province pendant l’un des trois exercices visés au paragraphe (4), il est versé à cette
dernière le montant total déduit à l’égard de la
surfacturation ou des frais modérateurs, selon le
cas.
Remboursement
à la province
Saving
(6) Nothing in this section restricts the power of the Governor in Council to make any order under section 15.
(6) Le présent article n’a pas pour effet de
limiter le pouvoir du gouverneur en conseil de
prendre le décret prévu à l’article 15.
Réserve
1984, c. 6, s. 20.
1984, ch. 6, art. 20.
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.
When deduction
made
Application aux
exercices
ultérieurs
1984, ch. 6, art. 21.
1984, c. 6, s. 21.
158
12
Canada Health Act — Annual Report 2010–2011
Santé — 11 juillet 2010
Regulations
REGULATIONS
RÈGLEMENTS
22. (1) Subject to this section, the Governor
in Council may make regulations for the administration of this Act and for carrying its purposes and provisions into effect, including,
without restricting the generality of the foregoing, regulations
22. (1) Sous réserve des autres dispositions
du présent article, le gouverneur en conseil
peut, par règlement, prendre toute mesure d’application de la présente loi et, notamment :
Règlements
a) définir les services visés aux alinéas a) à
d) de la définition de « services complémentaires de santé » à l’article 2;
(a) defining the services referred to in paragraphs (a) to (d) of the definition "extended
health care services" in section 2;
b) déterminer les services exclus des services hospitaliers;
(b) prescribing the services excluded from
hospital services;
c) déterminer les genres de renseignements
dont peut avoir besoin le ministre en vertu de
l’alinéa 13a) et fixer les modalités de temps
et autres de leur communication;
(c) prescribing the types of information that
the Minister may require under paragraph
13(a) and the times at which and the manner
in which that information shall be provided;
and
d) prévoir la façon dont il doit être fait état
du Transfert en vertu de l’alinéa 13b).
(d) prescribing the manner in which recognition to the Canada Health and Social Transfer is required to be given under paragraph
13(b).
Agreement of
provinces
(2) Subject to subsection (3), no regulation
may be made under paragraph (1)(a) or (b) except with the agreement of each of the
provinces.
(2) Sous réserve du paragraphe (3), il ne
peut être pris de règlements en vertu des alinéas
(1)a) ou b) qu’avec l’accord de chaque province.
Consentement
des provinces
Exception
(3) Subsection (2) does not apply in respect
of regulations made under paragraph (1)(a) if
they are substantially the same as regulations
made under the Federal-Provincial Fiscal Arrangements Act, as it read immediately before
April 1, 1984.
(3) Le paragraphe (2) ne s’applique pas aux
règlements pris en vertu de l’alinéa (1)a) s’ils
sont sensiblement comparables aux règlements
pris en vertu de la Loi sur les arrangements fiscaux entre le gouvernement fédéral et les provinces, dans sa version précédant immédiatement le 1er avril 1984.
Exception
Consultation
with provinces
(4) No regulation may be made under paragraph (1)(c) or (d) unless the Minister has first
consulted with the ministers responsible for
health care in the provinces.
(4) Il ne peut être pris de règlements en vertu des alinéas (1)c) ou d) que si le ministre a au
préalable consulté ses homologues chargés de
la santé dans les provinces.
Consultation des
provinces
R.S., 1985, c. C-6, s. 22; 1995, c. 17, s. 40.
L.R. (1985), ch. C-6, art. 22; 1995, ch. 17, art. 40.
Annual report by
Minister
REPORT TO PARLIAMENT
RAPPORT AU PARLEMENT
23. The Minister shall, as soon as possible
after the termination of each fiscal year and in
any event not later than December 31 of the
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
23. Au plus tard pour le 31 décembre de
chaque année, le ministre établit dans les
meilleurs délais un rapport sur l’application de
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
Canada Health Act — Annual Report 2010–2011
13
Rapport annuel
du ministre
159
Canada Health — July 11, 2010
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.
chambre du Parlement dans les quinze premiers
jours de séance de celle-ci suivant son achèvement.
1984, ch. 6, art. 23.
1984, c. 6, s. 23.
160
14
Canada Health Act — Annual Report 2010–2011
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 2010–2011
161
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
162
(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 2010–2011
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 2010–2011
1
163
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
164
Canada Health Act — Annual Report 2010–2011
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 2010–2011
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.
165
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 inter­
pretation 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.
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Canada Health Act — Annual Report 2010–2011
Annex B: Policy Interpretation Letters
Comprehensiveness
The intent of the Canada Health Act is neither to expand nor contract the range of insured services covered under
previous federal legislation. The range of insured services encompasses medically necessary hospital care, physician
services and surgical-dental services which require a hospital for their proper performance. Hospital plans are expected
to cover in-patient and out-patient hospital services associated with the provision of acute, rehabilitative and chronic
care. As regards physician services, the range of insured services generally encompasses medically required services
rendered by licensed medical practitioners as well as surgical-dental procedures that require a hospital for proper
performance. Services rendered by other health care practitioners, except those required to provide necessary hospital
services, are not subject to the Act’s criteria.
Within these broad parameters, provinces, along with medical professionals, have the prerogative and responsibility
for interpreting what physician services are medically necessary. As well, provinces determine which hospitals and
hospital services are required to provide acute, rehabilitative or chronic care.
Universality
The intent of the Canada Health Act is to ensure that all bonafide residents of all provinces be entitled to coverage and
to the benefits under one of the twelve provincial/territorial health care insurance plans. However, eligible residents
do have the option not to participate under a provincial plan should they elect to do so.
The Agreement on Eligibility and Portability provides some helpful guidelines with respect to the deter­m ination 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.
Canada Health Act — Annual Report 2010–2011
167
Annex B: Policy Interpretation Letters
In my discussions with provincial/territorial Ministers, I detected a desire to achieve these portability objectives and
to minimize the difficulties that Canadians may encounter when moving or travelling about in Canada. In order that
Canadians may maintain their health insurance coverage and obtain benefits or services without undue impediment, I believe that all provincial/territorial Health Ministers are interested in seeing these services provided more
efficiently and economically.
Significant progress has been made over the past few years by way of reciprocal arrangements which contribute
to the achievement of the in-Canada portability objectives of the Canada Health Act. These arrangements do not
interfere with the rights and prerogatives of provinces to determine and provide the coverage for services rendered
in another province. Likewise, they do not deter provinces from exercising reasonable controls through prior
approval mechanisms for elective procedures. I recognize that work remains to be done respecting interprovincial
payment arrangements to achieve this objective, especially as it pertains to physician services.
I appreciate that all difficulties cannot be resolved overnight and that provincial plans will require sufficient time to
meet the objective of ensuring no direct charges to patients for necessary hospital and physician services provided
in other provinces.
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-ofservice 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.
168
Canada Health Act — Annual Report 2010–2011
Annex B: Policy Interpretation Letters
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.
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].
Canada Health Act — Annual Report 2010–2011
169
Annex B: Policy Interpretation Letters
Regulations
Aside from the recognition and information regulations referred to above, the Act provides for regulations concerning
hospital services exclusions and regulations defining extended health care services.
As you know, the Act provides that there must be consultation and agreement of each and every province with
respect to such regulations. My consultations with you have brought to light few concerns with the attached draft set
of Exclusions from Hospital Services Regulations.
Likewise, I did not sense concerns with proposals for regulations defining Extended Health Care Services. These
help provide greater clarity for provinces to interpret and administer current plans and programs. They do not alter
significantly or substantially those that have been in force for eight years under Part VI of the Federal Post-Secondary
Education and Health Contributions Act (1977). It may well be, however, as we begin to examine the future challenges
to health care that we should re-examine these definitions.
This letter strives to set out flexible, reasonable and clear ground rules to facilitate provincial, as much as federal,
administration of the Canada Health Act. It encompasses many complex matters including criteria interpretations,
federal policy concerning conditions and proposed regulations. I realize, of course, that a letter of this sort cannot
cover every single matter of concern to every provincial Minister of Health. Continuing dialogue and communication are essential.
In conclusion, may I express my appreciation for your assistance in bringing about what I believe is a generally
accepted concurrence of views in respect of interpretation and implementation. As I mentioned at the outset of this
letter, I would appreciate an early written indication of your views on the proposals for regulations appended to this
letter. It is my intention to write to you in the near future with regard to the voluntary information exchanges which we
have discussed in relation to administering the Act and reporting to Parliament.
Yours truly,
Jake Epp
Attachments
170
Canada Health Act — Annual Report 2010–2011
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 out-patient basis or outside of full-service
hospitals. The accessibility criterion in the Act, of which the user charge provision is just a specific example, was
clearly intended to ensure that Canadian residents receive all medically necessary care without financial or other
barriers and regardless of venue. It must continue to mean that as the nature of medical practice evolves.
Second, as a matter of legal interpretation, the definition of “hospital” set out in the Act includes any facility which
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.
Canada Health Act — Annual Report 2010–2011
171
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 regu­latory framework. As of October 15, 1995, I will proceed to deduct from transfer payments any amounts charged for facility fees in respect of medically necessary services, as mandated by section 20
of the Canada Health Act. I believe this provides a reasonable transition period, given that all provinces have been
aware of my concerns with respect to private clinics for some time, and given the promising headway already made
by the Federal/Provincial/Territorial Advisory Committee on Health Services, which has been working for some
time now on the issue of private clinics.
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 accomodate 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 consul­t ations in all cases where there are disagreements. In situations such as out-of-province
172
Canada Health Act — Annual Report 2010–2011
Annex B: Policy Interpretation Letters
or out-of-country coverage, I remain committed to following through on these consultative processes as long as
they continue to promise a satis­factory conclusion in a reasonable time.
In closing, I would like to quote Mr. Justice Emmett M. Hall. In 1980, he reminded us:
“ we, as a society, are aware that the trauma of illness, the pain of surgery, the slow decline to death, are
burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing
the patient at the moment of vulnerability.”
I trust that, mindful of these words, we will continue to work together to ensure the survival, and renewal, of what
is perhaps our finest social project.
As the issues addressed in this letter are of great concern to Canadians, I intend to make this letter publicly
available once all provincial Health Ministers have received it.
Yours sincerely,
Diane Marleau
Minister of Health
Canada Health Act — Annual Report 2010–2011
173
174
Canada Health Act — Annual Report 2010–2011
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 provinces and territories, except Quebec. The process
meets federal and provincial/territorial interests of
avoiding disputes related to the interpretation of the
principles of the Canada Health Act, and when this is
not possible, resolving disputes in a fair, transparent
and timely manner.
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 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
Canada Health Act — Annual Report 2010–2011
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.
175
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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Canada Health Act — Annual Report 2010–2011
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 2010–2011
177
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.
As a first step, governments involved in the dispute
will, within 60 days of the date of the letter initiating
the process, jointly:
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.
• 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.
• 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.
178
Canada Health Act — Annual Report 2010–2011
Contact Information for Provincial and Territorial Departments of Health
Newfoundland and Labrador
Manitoba
Department of Health and Community Services
Confederation Building
P.O. Box 8700
St. John’s, NL A1B 4J6
(709) 729-5021
www.gov.nl.ca/health
Manitoba Health
300 Carlton Street
Winnipeg, MB R3B 3M9
1-800-392-1207
www.manitoba.ca/health
Prince Edward Island
Department of Health and Wellness
P.O. Box 2000
Charlottetown, PE C1A 7N8
(902) 368-6414
www.gov.pe.ca/health
Nova Scotia
Department of Health and Wellness
P.O. Box 488
Halifax, NS B3J 2R8
(902) 424-5818
www.gov.ns.ca/health/
New Brunswick
Department of Health
P.O. Box 5100
Fredericton, NB E3B 5G8
(506) 457-4800
www.gnb.ca/0051/index-e.asp
Saskatchewan
Saskatchewan Health
3475 Albert Street
Regina, SK S4S 6X6
1-800-667-7766
www.health.gov.sk.ca
Alberta
Alberta Health and Wellness
P.O. Box 1360, Station Main
Edmonton, AB T5J 2N3
(780) 427-1432
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
Quebec
Yukon
Ministry of Health and Social Services
1075 Sainte-Foy Road
Québec, QC G1S 2M1
(418) 266-7005
www.msss.gouv.qc.ca
Health and Social Services
Box 2703
Financial Plaza
Whitehorse, YT Y1A 2C6
1-867-667-5209
www.hss.gov.yk.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
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
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ANNUAL REPORT 2010–2011
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