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カナダ保健法年次報告書 2021 年
![Sep 18, 2023](/themes/hestia/images/news-details-icon1.webp)
Download in PDF format (9.9 MB, 416 pages)
Organization: Health Canada
Date published: 2023
Cat.: H1-4E-PDF
ISBN: 1497-9144
Pub.: 220753
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:
We also greatly appreciate the extensive work effort that was put into this report by our production team, including desktop publishers, translators, editors and concordance experts, printers and staff of Health Canada.
I am honoured to present to Parliament and to Canadians the Canada Health Act Annual Report 2021-2022.
As the federal Minister of Health one of my key responsibilities is to uphold the Canada Health Act which ensures that all Canadians have equitable access to essential health care services based on their need and not their ability, or willingness, to pay. My mandate letter also commits me to strengthening compliance with and modernizing the interpretation of the Act. I know that Canadians remain justifiably proud of our publicly funded health care system, but our system is also under significant pressure, which will require all levels of government to work together to ensure it meets the modern day needs of Canadians.
In order to ensure the long-term strength of the health system, working in partnership with provinces and territories, our work will focus on key priorities areas; 1) improving access to family health services; 2) addressing backlogs and supporting, attracting, and retaining health workers, 3) modernizing our health system with health data and digital health, 4) improving access to mental health and substance use services and 5) helping Canadians age with dignity, closer to home.
Medicare is a prime example of federal-provincial-territorial collaboration as health is a shared responsibility in Canada, and in order to achieve results and meet the health care needs of Canadians, all levels of government need to work together. The provincial and territorial governments have primary jurisdiction in health care delivery and administration, while the federal government defines the national requirements that must be reflected in health care insurance plans, under the Canada Health Act, which most jurisdictions not only meet but often exceed.
Over the course of the COVID-19 pandemic, we have seen what can be achieved when all levels of government work together in collaboration. To meet the health care needs of Canadians, we have seen the expansion of virtual care, telemedicine, and the scope of health care practitioners. Nonetheless, although our universal public health care system was an integral part in Canada's response to COVID-19, the pandemic has brought to light new challenges and amplified those already creating stress on our system. To this end, the provinces and territories have been working hard in the fight against COVID-19, to reduce backlogs exacerbated by the pandemic, and to recruit and retain health care workers.
Our collaborative work also extends to strengthening Canada's universal health care system by upholding the standards of the Canada Health Act. From a federal perspective, we are working hard to ensure that as our health care system evolves, so too does the interpretation and administration of the Canada Health Act, to better serve Canadians. We are taking action to combat patient charges, including those for surgical abortion services, diagnostics, as well as other insured services received in private clinics; and, for the first time, this coming March 2023, provinces and territories which permit charges for medically necessary diagnostic services, will also face deductions to their Canada Health Transfer payments. The aim of the Act is not to levy deductions but rather to work with the provinces and territories to ensure that Canadians have access to the care they need without barriers. As such, I would also like to recognize several jurisdictions for their collaborative work to eliminate patient charges in their respective jurisdictions and the underlying circumstances which led to them. Newfoundland and Labrador has been fully reimbursed all Canada Health Transfer deductions since 2019 and British Columbia has received several partial reimbursements in recognition of the elements of their Reimbursement Action Plan that have been successfully implemented. Copies of their respective Reimbursement Action Plans can be found in this report. British Columbia has also taken a strong legal stance in combatting patient charges in the province regarding access to necessary health care in private clinics, as well as more recently for access to virtual care. This action embodies the position we all share, that no one should be left behind or denied necessary health care, based on their ability or willingness to pay.
The pandemic has proven we are stronger together and when there is a will, all levels of government can work together to meet the health care needs of Canadians. In March 2022, I laid out my vision for the future of federal-provincial-territorial collaboration on health care in Canada. I look forward to continuing our collaboration, respecting the jurisdiction of the various levels of government, sharing in our joint responsibility to provide Canadians with the care they need, and delivering on better health care results for everyone.
This section describes the evolution of Medicare in Canada, as well as the Canada Health Act, its key definitions, requirements, regulations, penalty provisions, and excluded persons and services under the Act. It also outlines interpretation letters from former federal Ministers of Health sent to their provincial and territorial counterparts, following months of consultation:
Canada's single-payor public health care insurance system, "Medicare", is financed through a progressive tax system, which allows risks to be pooled and costs to be shared by all Canadians. Our health care insurance system evolved into its present form over more than six decades. Saskatchewan was the first province to establish universal, public hospital insurance in 1947 and, 10 years later, the Government of Canada passed the Hospital Insurance and Diagnostic Services Act (HIDSA), to encourage provinces and territories to provide universal coverage for these services by sharing in their costs. The unanimous adoption of HIDSA by the federal Parliament launched the largest single program ever undertaken in peace-time Canada and, 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 encourage provinces and territories to provide universal coverage for physician services by sharing in their costs. By 1972, all provincial and territorial plans had been extended to include physician services.
In 1979, at the request of the federal government, Justice Emmett Hall undertook a review of the state of health services in Canada. In his report, he affirmed that health care services in Canada ranked among the best in the world, but warned that extra-billing by doctors and user charges levied by hospitals were creating a two-tiered system that threatened the universal accessibility of care. This report, and the national debate it generated, led to the enactment of the Canada Health Act.
"…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. The Canadian people determined that they should band together to pay medical bills and hospital bills when they were well and income earning. Health services were no longer to be bought off the shelf and paid for at the checkout stand. Nor was their price to be bargained for at the time they were sought. They were a fundamental need, like education, which Canadians could meet collectively and pay for through taxes."
Justice Emmett M. Hall, Canada's National-Provincial Health Program for the 1980's, 'A Commitment for Renewal', (Health services Review 1979-1980), Chapter 1, pg. 6, August 29, 1980
Passed unanimously in the House of Commons in 1984, the Canada Health Act, Canada's federal health care insurance legislation, codified the national principles which underpin federal funding for hospital and physician services and added prohibitions on the patient charges which threatened to undermine universal access to care.
In Canada, the roles and responsibilities for health are shared between the federal, provincial and territorial governments. The provincial and territorial governments have primary jurisdiction in health care administration and delivery. This includes setting their own priorities, administering their health care budgets and managing their own resources. The federal government, under the Canada Health Act, defines the national principles that are to be reflected in provincial and territorial health care insurance plans.
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). In fiscal year 2021-2022, the CHT was $43,126,000,000. Additional information on federal, provincial and territorial funding arrangements is available by visiting the Department of Finance's website at: https://www.canada.ca/en/department-finance/programs/federal-transfers/major-federal-transfers.html
The aim of the Act is to ensure that all eligible residents of Canadian provinces and territories have reasonable access to medically necessary hospital, physician, and surgical-dental services that require a hospital setting, on a prepaid basis, without charges related to the provision of insured health care services.
A copy of the Act is provided in Annex A.
Medicare is a fundamental part of Canada's national identity and represents Canadians’ ongoing commitment to the values of equity, fairness, and solidarity. These same values can be seen reflected in the preamble of the Act, which states 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".
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 procedures) provided to insured persons, unless those services are provided under another Act of Parliament, or provincial or territorial workers’ compensation legislation.
Extended health care services 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.
Insured persons are eligible residents of a province or territory. A resident of a province is defined in the Act as "… a person lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province…"
Insured hospital services include medically necessary in-patient 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 anesthetic facilities, including necessary equipment and supplies; medical and surgical equipment and supplies; use of radiotherapy facilities; use of physiotherapy facilities; and services provided by persons who receive remuneration therefor from the hospital.
Insured physician services are medically required services rendered by medical practitioners. Medically required physician services are generally determined by the provincial or territorial health care insurance plan, in consultation with the medical profession.
Insured surgical-dental services are services provided by a dentist in a hospital, where a hospital setting is required for the proper performance of the procedure.
".... The promise of our healthcare system is for equitable access. In other words, our healthcare system, at least with respect to medically necessary care, is premised on a principle of fairness. Patients will be prioritized based on their medical needs and not their ability to pay."
Cambie Surgeries Corporation v. British Columbia (Attorney General), 2020 BCSC 1310, Page 539, Paragraph 1974
The Canada Health Act Infographic
Canada Health Act Infographic
If the provinces and territories fulfill the Canada Health Act's criteria and conditions:
Five Criteria:
Two Conditions:
And ensure there are no patient charges for insured health services that constitute extra-billing or user charges
They are entitled to their full Canada Health Transfer
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:
The public administration criterion of the Canada Health Act requires provincial and territorial health care insurance plans to be administered and operated on a non-profit basis by a public authority, which is accountable to the provincial or territorial government for decision-making on benefit levels and services, and whose records and accounts are publicly audited. However, the criterion does not prevent the public authority from contracting out the services necessary for the administration of the provincial and territorial health care insurance plans, such as the processing of payments to physicians for insured health care services.
The public administration criterion pertains only to the administration of provincial and territorial health care insurance plans and does not preclude private facilities or providers from supplying insured health care services as long as no insured person is charged in relation to the provision of these insured health services.
The comprehensiveness criterion requires that the health care insurance plan of a province or territory must cover all insured health care services provided by hospitals, physicians or dentists (i.e., surgical-dental services that require a hospital setting).
Under the universality criterion, all insured residents of a province or territory must be entitled to the insured health care services provided by the provincial or territorial health care insurance plan on uniform terms and conditions. Provinces and territories generally require that residents register with the plan to establish entitlement.
Residents moving from one province or territory to another must continue to be covered for health care services insured by the home jurisdiction during any waiting period imposed by the new province or territory of residence (up to three months), before coverage is established in the new jurisdiction. 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, in order to avoid any gaps in coverage.
Residents who are temporarily absent from their home province or territory, or from Canada, must continue to be covered for insured health care services by their home province or territory. If insured persons are temporarily absent in another province or territory, the portability criterion requires that insured services be paid at the host province's rate. If insured persons are temporarily out of the country, insured services are to be paid at the home province's rate.
The portability criterion is intended to permit a person to receive medically necessary services in relation to an urgent or emergent need, when absent on a temporary basis (e.g., business or vacation) but does not entitle residents to seek services or shorter waits for non-urgent or emergent services, without prior approval.
Prior approval by the health care insurance plan in a person's home province or territory may be required before coverage is extended for elective (non-emergency) services to a resident while temporarily absent from their province or territory.
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 that require a hospital setting, on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by charges (extra-billing or user charges) or other means (e.g., discrimination on the basis of age, race, health status, or financial circumstances).
Reasonable access in terms of physical availability of medically necessary services has been interpreted under the Canada Health Act using the "where and as available" principle. Thus, residents of a province or territory are entitled to have access on uniform terms and conditions to insured health care services at the setting "where" the services are provided and "as" the services are available in that setting. For example, if a hospital in one region of a province was providing highly specialised services, that would not mean that all hospitals in the province would be required to provide the same service. Rather, it means that all residents of the province should have access to the service wherever it is being offered, on the same basis.
In addition, the health care insurance plan of the province or territory must provide:
The provincial and territorial governments are required to provide information to the federal Minister of Health as prescribed by regulations under the Act.
The provincial and territorial governments are required to recognize the federal financial contributions toward both insured and extended health care services.
The provisions of the Canada Health Act pertaining to extra-billing and user charges for insured health care 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 dollar-for-dollar deduction from the CHT payments to that province or territory is required under the Act.
Under the Act, extra-billing is defined as a charge by an enrolled medical practitioner or dentist (i.e., a dentist providing insured surgical-dental services in a hospital setting) to an insured person for an insured service in addition to the amount paid by the provincial or territorial health care insurance plan. For example, if an enrolled physician were to charge a patient any amount for an office visit that is insured by the provincial or territorial health care insurance plan, the amount charged would constitute extra-billing. Extra-billing is seen as a barrier for people seeking medical care, and is contrary to the accessibility criterion.
A user charge is defined as any charge for an insured health care service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private practice). In other words, if patients were charged a fee as a condition of receiving insured health care services, 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 to access.
What is a patient charge?
What is a Patient Charge? Infographic
Section 22 of the Canada Health Act enables the federal government to make regulations for administering the Act in the following areas:
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 report annually to Health Canada on the amounts of extra-billing and user charges levied. A copy of these Regulations is provided in Annex A.
Under the Act, provinces and territories that allow extra-billing and user charges are subject to mandatory dollar-for-dollar deductions from the federal transfer payments under the CHT. For example, if it is determined that any amount of extra-billing by physicians has occurred in a province or territory, the federal cash contribution to that province or territory will be reduced by that same amount. Although deductions are usually based on information provided by the province or territory in accordance with the Extra-billing and User Charges Information Regulations, where information is not provided, or is incomplete, Health Canada will make an estimate of the amount of extra-billing and user charges. This process requires consultation with the province or territory concerned. Deductions based on estimates have been made on numerous occasions.
Provincial and territorial financial statements of extra-billing and user charges received during the reporting period are provided in Annex B.
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 CHT payments is based on the magnitude of the non- compliance, and is approved by Cabinet.
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 used.
Although the Canada Health Act requires that insured health care services be provided to insured persons in a manner that is consistent with the criteria and conditions set out in the Act, not all health care services or Canadian residents fall under the scope of the Act.
A number of services provided by hospitals and physicians are not considered medically necessary, and, thus, are not insured under provincial and territorial health care insurance legislation. Uninsured hospital services for which patients may be charged include preferred hospital accommodation (unless prescribed by a physician or when standard ward level accommodation is unavailable), private duty nursing services, parking, and the provision of telephones and televisions. Uninsured physician services for which patients may be charged include telephone advice (unless it is insured by the provincial or territorial health care insurance plan, as it has been during the COVID-19 pandemic); the provision of medical certificates (e.g., for work, school, insurance purposes); the transfer of medical records; testimony in court; and cosmetic services. Amounts for these services are governed by provincial and territorial Colleges of Physicians, which generally require that charges be reasonable and reflect the cost of services provided.
The definition of "insured health services" excludes services provided to persons under any other Act of Parliament (e.g., certain services provided to veterans) or under the workers' compensation legislation of a province or territory.
In addition to the medically necessary hospital and physician services covered by the Canada Health Act, provinces and territories also provide a wide range of other programs and services, such as prescription drug coverage, non-surgical dental care, ambulance services and optometric services, at their discretion and on their own terms and conditions. These services are often targeted to specific population groups (e.g., seniors, children, and those receiving social assistance), with levels of funding and scope of coverage varying from one province or territory to another.
The Canada Health Act definition of "insured person" excludes members of the Canadian Armed Forces and persons serving a term of imprisonment within a federal penitentiary. The Government of Canada provides coverage to these groups through separate federal programs.
The exclusion of these persons from insured health care service coverage predates the adoption of the Act and is not intended to constitute differences in access to publicly insured health care.
There are three 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, following months of consultation. Copies of the letters are provided in Annex C of this report
In June 1985, approximately one year following the passage of the Canada Health Act in Parliament, federal Minister of Health and Welfare Jake Epp wrote to his provincial and territorial counterparts to set out and confirm the federal position on the interpretation and implementation of the Act. The letter sets forth statements of federal policy intent that clarify the Act's criteria, conditions and regulatory provisions. The letter highlighted the fundamental change signified by the Canada Health Act, which was the prohibition of all patient charges for insured services provided to insured residents. The Epp letter remains an important reference for assessing and interpreting compliance with the Act.
Between February and December of 1994, a series of seven federal, provincial and 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 and 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 were required to regulate the development of private clinics in Canada."
Diane Marleau, the federal Minister of Health at the time, wrote to all provincial and territorial Ministers of Health on January 6, 1995, to announce the new Federal Policy on Private Clinics. The Minister's letter provided the federal interpretation of the Canada Health Act as it relates to the issue of facility fees charged directly to patients receiving medically necessary services at private clinics. The letter stated that the definition of hospital contained in the Act includes any public facility that provides acute, rehabilitative or chronic care. Thus, when a provincial or territorial health care 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.
On August 8, 2018, the former federal Minister of Health, Ginette Petitpas Taylor, wrote to her provincial and territorial counterparts formalizing three new Canada Health Act initiatives – the Diagnostic Services Policy, the Reimbursement Policy, and strengthened Canada Health Act reporting. These initiatives were the subject of discussion at the federal, provincial and territorial officials' level and adjustments were made to the requirements of these initiatives based on feedback received from the provinces and territories.
The Diagnostic Services Policy came into effect on April 1, 2020. This policy is a formalization of the application of the Canada Health Act to diagnostic services. It confirms the longstanding federal position that medically necessary services, including diagnostic services, are insured regardless of the venue where the services are delivered. Under this policy, provinces and territories first reported on patient charges for medically necessary diagnostic services in December 2022 (for any patient charges which occurred during 2020–2021) and will be published in the 2022-2023 Canada Health Act Annual Report.
Since April 1, 2020, any patient charges for medically necessary diagnostic imaging services, such as MRI or CT scans, regardless of where these services are provided, have been considered contrary to the Canada Health Act. If you believe you have been charged inappropriately, you may report these charges to your provincial or territorial health ministry, using the phone numbers provided inside the back cover of this report. You may also contact the Canada Health Act Division of Health Canada at the following coordinates:
Should a province or territory be subject to a mandatory deduction, the federal Minister of Health has the discretion to provide a reimbursement if the province or territory eliminates the patient charges that led to the deductions within a specified timeframe. The first deductions eligible for reimbursement under the policy were those taken in March 2018.
The aim of strengthened Canada Health Act reporting is to ensure Health Canada has the information required to accurately assess compliance with the Act, as well as to increase transparency for Parliament and Canadians on the administration of the Act, and the state of the publicly funded health care insurance system.
While you may not have to pay upfront when you receive medically necessary services, health care in Canada is not free. Health care in Canada is funded through tax revenues at the provincial, territorial, and federal levels. By spreading the cost of health care across the entire population, everyone is assured of the care they need, without the great financial burden that medical expenses could pose to a family or individual.
If you believe you have been subject to inappropriate patient charges for insured health services please contact your respective province or territory using the information contained in the Contact Information section of the report, or by contacting the Canada Health Act Division at [email protected].
In administering the Canada Health Act, the federal Minister of Health (the Minister) is assisted by Health Canada staff and by the Department of Justice.
The Canada Health Act Division of Health Canada is responsible for supporting the Minister in the administration of the Canada Health Act. Members of the Division fulfill the following ongoing functions:
Health Canada continues to work with provinces and territories on the challenges of managing virtual care and the expanding scope of health care practitioners. The federal government will ensure that while the Canadian health care system evolves and integrates new forms of health care delivery, the requirements of the Canada Health Act are respected.
The Canada Health Act Division monitors the operations of provincial and territorial health care insurance plans in order to provide advice to the Minister on possible non-compliance with the Canada Health Act. Sources for this information include: provincial and territorial government officials and publications; nongovernmental organizations; media reports; and correspondence received from the public.
Staff in the Canada Health Act Division assess issues of concern and complaints on a case-by-case basis. The assessment process involves compiling all facts and information related to the issue and taking appropriate action. Verifying the facts with provincial and territorial health officials sometimes reveals issues that are not directly related to the Act, while others may pertain to the Act but are a result of misunderstanding or miscommunication, such as eligibility for health care insurance coverage and portability of health services within and outside Canada. In these instances, matters are generally resolved quickly with provincial or territorial assistance.
In instances where a Canada Health Act issue has been identified and remains after initial enquiries, Division officials ask the jurisdiction in question to investigate the matter and report back. Division staff discuss the issue and its possible resolution with provincial or territorial officials. Only if the issue is not resolved to the satisfaction of the Division after following the aforementioned steps, is it brought to the attention of the federal Minister of Health.
For the most part, provincial and territorial health care insurance plans meet the requirements of the Canada Health Act. However, some issues and concerns remain. The most prominent of these relate to accessibility issues, and specifically patient charges for medically necessary health services at private clinics.
On the basis of its health ministry's report to Health Canada, a deduction in the amount of $1,723 was taken from the March 2022 Canada Health Transfer (CHT) payments to Newfoundland and Labrador in respect of user charges for insured health services provided by an enrolled physician at a private ophthalmological clinic in fiscal year 2019–2020. The province worked collaboratively with Health Canada to implement a mutually agreed-upon Reimbursement Action Plan (RAP). Newfoundland and Labrador successfully addressed and eliminated the underlying circumstances that led to these patient charges and has received full reimbursements of its March 2019, 2020, 2021, and 2022 deductions. A copy of Newfoundland and Labrador's RAP as well the January 2023 status update on its implementation are presented in Annex D of this report.
In New Brunswick, surgical abortion services are insured under the provincial health insurance plan but are only covered if performed in hospital; procedures provided in the private clinic in Fredericton are not covered. Health Canada has raised this issue with New Brunswick at the officials' level and Ministerial levels.
Although the province's financial statement of extra-billing and user charges for 2019-2020 indicated a nil amount, Health Canada used evidence provided by Clinic 554, as well as data published by the Canadian Institute for Health Information, to estimate patient charges for fiscal year 2019-2020 in the amount of $64,850, and a deduction in the same amount was taken from New Brunswick's March 2022 CHT payment.
While the Ontario Health Insurance Plan provides coverage for physicians' fees related to abortion services in all settings, including private clinics, the province only covers facility fees in the four private abortion clinics licensed as Independent Health Facilities (IHF). In some instances, this has led to clinics charging patients out-of-pocket to access abortion services. Based on patient charges reported by Ontario to Health Canada, a deduction of $6,560 was levied against the province's CHT payment in March 2022 for patient charges that occurred in fiscal year 2019-2020. In December 2021, Ontario submitted a Reimbursement Action Plan (RAP) to Health Canada, in which it committed to revisiting the current framework for the funding of insured surgical abortion services in the province. Health Canada continues to engage with Ontario as it works to implement its RAP. A copy of Ontario's RAP as well the February 2023 status update on its implementation are presented in Annex D of this report.
British Columbia submitted a financial statement of extra-billing and user charges for fiscal year 2019–2020, in the amount of $13,275,823. A deduction in the same amount was taken from the province's March 2022 CHT payment. In recognition of the significant strides British Columbia has made in successfully implementing elements of its Reimbursement Action Plan (RAP), and the elimination of patient charges, during the reporting period, Health Canada authorized a reimbursement of $20,518,055 in March 2022. This represents a partial reimbursement of British Columbia's March 2020, 2021, and 2022 deductions. A copy of the RAP and January 2023 status update are presented in Annex D of this report.
The Diagnostic Services Policy, in effect since April 1, 2020, aims to eliminate patient charges for medically necessary diagnostic services, such as MRI and CT scans. This policy formalizes the longstanding federal position that medically necessary diagnostic services are insured health services regardless of where they are provided (i.e., in hospital or a private clinic).
While Saskatchewan is the only province that expressly encourages this practice through legislation, there is evidence of residents paying out-of-pocket to access diagnostic services in other provinces, including British Columbia, Alberta, Manitoba, Quebec, New Brunswick, and Nova Scotia.
Provinces and territories that permit patients to be charged for these services were first required to report on these charges in December 2022 and will be subject to deductions from federal transfers under the Canada Health Act. If provinces and territories eliminate these patient charges and the circumstances that led to them, they may be eligible for reimbursement of their deductions under the Reimbursement Policy. Health Canada continues to consult with provinces and territories to provide assistance and guidance on the Diagnostic Services Policy.
Executive and primary health clinics that charge patients enrollment and annual membership fees continue to be an issue of concern under the Canada Health Act and engagement with jurisdictions where such clinics exist (British Columbia, Manitoba, Ontario, Quebec, and Nova Scotia) is ongoing. These clinics provide their members with access to a mix of insured primary care services and uninsured services (e.g., massage therapy and nutritional services). Typically, the clinics claim that the fees cover a basket of non-insured services; however, in some cases these fees are also mandatory to access insured services at the clinic (i.e., physician services). Health Canada continues to press this issue, encouraging provinces and territories, where such fees exist, to make clear to insured residents that access to insured services is not contingent on the payment of annual fees for uninsured services. Health Canada also encourages these provinces and territories to develop legislation that is clear about patients’ access to insured services and which prohibits out-of-pocket charges to patients.
Physician services received by Quebec residents when out-of-province are not reimbursed at host province rates, which is a requirement of the portability criterion of the Canada Health Act. For all jurisdictions, except Prince Edward Island and the three territories, the per diem rates for out-of-country hospital services appear lower than home province or territory rates, which is contrary to the requirement of the portability criterion of the Act.
Since the beginning of the pandemic the federal government has provided provinces and territories an additional $6.5 billion in top-ups to the Canada Health Transfer to help with the fight against COVID-19. In 2019-2020, $500 billion was provided as part of the COVID-19 Response Fund as well as $4 billion in 2020-2021 and an additional $2 billion in 2021-2022 to reduce backlogs of surgeries and procedures exacerbated by the pandemic.
The Canada Health Act, which came into force April 17, 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 in which patients had been subject to extra-billing and user charges had taken appropriate steps to eliminate them. Accordingly, by June 1987, a total of $244,732,000 in deductions was refunded to New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia.
In the first three years after the enactment of the Canada Health Act, almost $245 million in deductions were taken against federal health transfers to provinces; these deductions were refunded when the provinces effectively eliminated the patient charges that led to them.
Following the Act's initial three-year transition period, during which refunds to provinces and territories for deductions were possible, penalties under the Act did not reoccur until fiscal year 1994–1995. See the chart later in this chapter for penalties occurring from fiscal years 1994–1995 to 2016-2017.
In the early 1990s, as a result of a dispute between the British Columbia Medical Association and the British Columbia government over compensation, several doctors opted out of the provincial health care 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 care insurance plan.
This higher amount constituted extra-billing under the Act. Deductions began in May 1994, relating to fiscal year 1992–1993, and continued until extra-billing by physicians was banned when changes to British Columbia's Medicare Protection Act came into effect in September 1995. In total, $2,025,000 was deducted from British Columbia's cash contribution for extra-billing that occurred in the province between 1992–1993 and 1995–1996.
Under the Canada Health Act, the term "hospital" includes more than just buildings with a big "H" on them.
Under the 1995 Federal Policy on Private Clinics, the Honourable Diane Marleau, the federal Minister of Health at the time, clarified that the definition of "hospital" set out in the Canada Health Act includes any facility that provides acute, rehabilitative, or chronic care. As such, a hospital also covers health care facilities, such as clinics.
In January 1995, federal Minister of Health, the Honourable 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 surgical 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 Act. Accordingly, beginning in November 1995, the deductions described below were applied to the cash contributions to Newfoundland and Labrador, Nova Scotia, Manitoba, and Alberta for non-compliance with the Federal Policy on Private Clinics.
A total of $280,430 was deducted from Newfoundland and Labrador's cash contribution due to facility fees in a private abortion clinic, before these fees were eliminated, effective January 1, 1998.
Before it closed in November 2003, deductions totaling $372,135 were made to Nova Scotia's Canada Health and Social Transfer (CHST) cash contribution for its failure to cover facility charges to patients, while paying the physician fee, at a Halifax clinic. A final deduction of $5,463 was taken from the March 2005 CHT payment to Nova Scotia as a reconciliation of deductions that had already been taken for 2002–2003. A one-time positive adjustment in the amount of $8,121 was made to Nova Scotia's March 2006 CHT payment to reconcile amounts actually charged in respect of extra-billing and user charges with the penalties that had already been levied based on provincial estimates reported for fiscal 2003–2004.
From November 1995 to December 1998, deductions totaling $2,055,000 were taken due to user charges anticipated by the province at surgical and ophthalmology clinics. However, during fiscal year 2001–2002, a monthly deduction (from October 2001 to March 2002, inclusively) in the amount of $50,033.50 was levied against Manitoba's CHST cash contribution on the basis of a financial statement provided by the province. The statement showed that actual amounts charged with respect to user charges for insured health 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.
Deductions of $3,585,000 were made, from November 1995 until June 1996, 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 care insurance plan.
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 in private surgical clinics during fiscal year 2000–2001, totaling $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. As a result of reports that British Columbia was investigating 55 cases of user charges, a $126,775 deduction was taken from British Columbia's March 2004 CHST payment, based on the amount the federal Minister estimated to have been charged during fiscal year 2001–2002.
Between 2002–2003 and 2016–2017, deductions totaling $1,773,183 were taken from British Columbia's Canada Health Transfer payments in light of patient charges reported by the province to Health Canada. The deduction taken to British Columbia's federal health transfers in 2012–2013, in respect of fiscal year 2010–2011, was estimated by the federal Minister of Health and represents the aggregate of the amounts reported to Health Canada by British Columbia and those reported publicly as the result of an audit performed by the Medical Services Commission of British Columbia. This methodology was used until fiscal year 2016–2017.
A deduction of $1,100 was taken from the March 2005 CHT payment to Newfoundland and Labrador as a result of patient charges for an MRI scan in a hospital which occurred during 2002–2003.
From March 2011 to March 2013, deductions totaling $102,249 were taken from CHT payments to Newfoundland and Labrador for extra-billing and user charges, based on charges reported by the province to Health Canada. These charges resulted from services provided by an opted-out dental surgeon who has since left the province.
The March 2007 CHT payment to Nova Scotia was reduced by $9,460 in respect of extra-billing during fiscal year 2004–2005. This amount was reported to Health Canada by the province based on the findings of an audit, concluded in 2006, of the billing practices of a Nova Scotia physician.
In March 2017, on the basis of amounts of extra-billing and user charges reported by the Quebec Auditor General with respect to accessory fees charged in 2014–2015, the federal Minister estimated a deduction amount of $9,907,229. In light of corrective action the provincial government had already taken to eliminate accessory fees in January 2017, that amount was subsequently returned to Quebec by the Government of Canada.
Since the passage of the Act, from April 1984 to March 2022, deductions totaling $114,959,087 have been taken from transfer payments in respect of the extra-billing and user charges provisions of the Act. This amount excludes deductions totaling $244,732,000 that were made between 1984 and 1987, and subsequently refunded to the provinces when extra- billing and user charges were eliminated.
This amount was subsequently refunded to the province in light of corrective actions the provincial government had already taken to address the issue of accessory fees at the time of the deduction.
Table 2 Return to footnote 1 referrer
Understanding This Chart
The first deductions under the Act were taken during the first three years after the Act's passage and were subsequently refunded. They are described earlier in this chapter and listed in a chart. There were no deductions taken between fiscal year 1987–1988 and 1993–1994.
To date, most deductions have been based on statements of actual extra-billing and user charges, meaning they are made two years after the extra-billing and user charges occurred (for example, deductions taken in fiscal year 2016–2017 would be in respect of patient charges levied in 2014–2015).
In instances where provinces and territories estimate anticipated amounts of extra-billing and user charges for the upcoming year, a deduction was taken in respect of those charges in the fiscal year for which they are estimated.
In addition to forming the basis for most deductions under the Act, the statements of actual extra-billing and user charges provide an opportunity to reconcile any estimated charges with those that actually occurred. These reconciliations form the basis for further modifications to provincial and territorial cash transfers.
As described earlier, the Canada Health Act Reimbursement Policy came into effect in 2018, to provide a positive incentive for provinces and territories to come into compliance, should they be subject to mandatory penalties as a result of patient charges for insured health services. The federal Minister of Health now has the discretion to provide a reimbursement if the province or territory eliminates those charges, and the underlying circumstances which led to the charges, within a specified timeframe. The first deductions eligible for reimbursement under the policy were those taken in March 2018.
In March 2019, a deduction of $1,349 was taken from CHT payments to Newfoundland and Labrador for extra-billing and user charges, based on patient charges for insured health services at a private ophthalmological clinic that occurred in 2016–2017, reported by the province to Health Canada. Similarly, a deduction of $70,819 was taken in March 2020, $4,521 in March 2021, and $1,723 in March 2022 in respect of charges in this clinic during 2017–2018, 2018-2019, and 2019-2020 respectively.
After its March 2019 deduction, Newfoundland and Labrador consulted with Health Canada on a Reimbursement Action Plan to eliminate patient charges. Given the province successfully carried out that plan, and eliminated these patient charges, the province qualified for full reimbursement of its March 2019 deduction as well as for immediate and full reimbursements of its March 2020, 2021, and 2022 deductions.
In March 2020, on the basis of evidence of patient charges for access to abortion services during 2017–2018, a deduction of $140,216 was taken to New Brunswick's CHT payments. A further $64,850 was deducted from the province's CHT payment in both March 2021 and March 2022 for patient charges levied during 2018-2019 and 2019-2020, respectively. The 2021 and 2022 deductions were estimated based on patient charges reported by Clinic 554 and data published by the Canadian Institute for Health Information. As long as New Brunswick refuses to cover insured abortion services outside hospitals, and patients face charges in the clinic setting, the province will continue to be subject to mandatory CHT deductions.
In March 2018, using the amount of extra-billing and user charges reported by the Quebec Auditor General with respect to accessory fees charged in 2014–2015 as a proxy, the federal Minister estimated a deduction amount of $9,907,229. In light of corrective action the provincial government had already taken to eliminate accessory fees in January 2017, this amount was subsequently returned to Quebec by the Government of Canada. This reimbursement pre-dated the Reimbursement Policy. Quebec's March 2017 and March 2018 deductions, which, due to reporting timelines under the Act, were taken after patient charges had already been eliminated by the provincial government, served as the inspiration for the Reimbursement Policy.
A further deduction of $8,256,024 was taken to Quebec's March 2019 federal health transfer, reflecting patient charges which had occurred prior to the corrective action taken by Quebec and was immediately reimbursed. This reimbursement was the first made under the Reimbursement Policy.
In March 2021, a deduction of $13,905 was taken from Ontario's federal health transfer for patient charges that occurred in 2018-2019. A further deduction of $6,560 was taken in March 2022. The deduction represents overhead costs charged to patients seeking abortion services at clinics that do not receive funding under Ontario's Independent Health Facilities Act.
Following collaborative work with Health Canada on an audit project to determine the extent and scope of patient charges in the province, a deduction of $15,861,818 was taken in March 2018 in respect of patient charges during fiscal year 2015–2016. This deduction reflected British Columbia's private clinic audit results, patient complaints, and publicly available evidence of $4.7 million of patient charges to insured residents by enrolled physicians at the Cambie Surgery Centre. A similar methodology was used to calculate the province's Canada Health Transfer deductions in March 2019 ($16,177,259), March 2020 ($16,753,833), March 2021 ($13,949,979), and March 2022 ($13,275,823).
Following the implementation of the Canada Health Act Reimbursement Policy in 2018, British Columbia consulted with Health Canada on a Reimbursement Action Plan to eliminate patient charges. Because the province successfully carried out some elements of that plan, the province received partial reimbursements, including: $16,019,539 in March 2020 (for 2018 and 2019 deductions), $24,509,418 in March 2021 (for 2019, 2020, and 2021 deductions), and $20,518,055 in March 2022 (for 2020, 2021, and 2022 deductions).
This amount was subsequently refunded to the province in light of corrective actions the provincial government had already taken to address the issue of accessory fees at the time of the deduction.
Table 3 Return to footnote 1 referrer
This amount represents a partial reimbursement of British Columbia's March 2018 (50%) and March 2019 (50%) deductions and was issued based on the elements of the province's Reimbursement Action Plan that were successfully carried out.
Table 3 Return to footnote 2 referrer
This amount represents an additional partial reimbursement of British Columbia's March 2019 ($3,327,622) as well as partial reimbursements of its March 2020 ($11,992,825) and March 2021 ($9,188,971) deductions and was issued based on the elements of the province's Reimbursement Action Plan that were successfully carried out.
Table 3 Return to footnote 3 referrer
This amount represents an additional partial reimbursement of British Columbia's March 2020 deduction ($4,284,907) as well as partial reimbursements of its March 2021 ($4,284,907) and March 2022 ($11,948,241) deductions and was issued based on the elements of the province's Reimbursement Action Plan that were successfully carried out.
Table 3 Return to footnote 4 referrer
Since the Canada Health Act Reimbursement Policy came into effect, $69,381,448 has been reimbursed to provinces, in recognition of their efforts to eliminate patient charges for insured health services.
All provinces and territories participate in hospital reciprocal billing agreements, and all, with the exception of Quebec, participate in physician reciprocal billing agreements. These agreements generally ensure that a patient's health care insurance card will be accepted, in lieu of payment, when the patient receives insured hospital or physician services in another province or territory. The province or territory providing the service will then directly bill the patient's home province at agreed-upon rates. The intent of these agreements is to ensure that Canadian residents do not have to pay directly for medically necessary hospital and physician services when they travel within Canada or during the waiting period for coverage to be established after moving to another province or territory. While the agreements facilitate the portability criterion of the Canada Health Act, provinces and territories may agree to meet the requirements of the Act through other mechanisms.
The Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC) was formed in 1991 as the authority to oversee the administration of the reciprocal billing agreements and ensure interprovincial/territorial health care coverage in accordance with the Act. IHIACC's mandate also includes analyzing and developing policy recommendations on interprovincial/territorial health care coverage issues outside the scope of the Act. The Committee includes members from each province and territory and a non-voting chair from the Canada Health Act Division. The Canada Health Act Division also provides secretariat functions for IHIACC. IHIACC maintains several working groups that support its mandate through the provision of strategic advice and recommendations related to reciprocal billing rates, patient eligibility, and interprovincial/territorial health care coverage policies.
Throughout 2021, IHIACC made progress on policy work to allow provincially-nominated mental health hospitals to bill reciprocally for emergency mental health services and began investigating reciprocal billing in the context of virtual care.
The following chapter presents the 13 provincial and territorial health care 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's program criteria and conditions in 2021-2022.
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:
The narrative component is used to help with the monitoring and compliance of provincial and territorial health care insurance plans with respect to the requirements of the Act, while statistics help to identify current and future trends in the Canadian health care system. While all provinces and territories have submitted detailed descriptive information on their health care insurance plans, Quebec chose not to submit supplemental statistical information which is contained in the tables in this year's report.
To help provinces and territories prepare their submissions to the annual report, Health Canada provided them with the document; Canada Health Act Annual Report 2021-2022: A Guide for Updating Submissions (User's Guide). The User's Guide is designed to help provinces and territories meet Health Canada's reporting requirements. Annual revisions to the guide are based on Health Canada's analysis of health care insurance 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 2021-2022 was launched summer 2022 with bilateral teleconferences. An updated User's Guide was also sent to the provinces and territories at that time.
For the following chapter, provincial and territorial officials were asked to provide a narrative description of their health care 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.
Participating Physician or Dentist is a licensed physician or dentist who is enrolled in a provincial or territorial health care insurance plan.
Non-Participating Physician or Dentist practises completely outside a provincial or territorial health care insurance plan. Neither the physician or dentist nor the patient is eligible for any cost coverage for services rendered or received from the provincial or territorial health care insurance plans. A non-participating physician or dentist may therefore establish their own fees, which are paid directly by the patient.
Opted-out Physician or Dentist is a physician or dentist who is enrolled in the provincial or territorial health insurance plan but has voluntarily opted out of the plan and will therefore bill their patients directly. These charges can be up to, but not more than, the provincial or territorial amount allowed under the fee schedule agreement. The provincial or territorial plans reimburse patients of opted-out physicians or dentists for these charges.
Over time, the section of the annual report containing the statistical information submitted from the provinces and territories has been simplified and streamlined based on feedback received from provincial and territorial officials, and based on reviews of data quality and availability. The supplemental statistical information tables can be found at the end of each provincial or territorial narrative, except for Quebec.
The purpose of the statistical tables is to place the administration and operation of the Canada Health Act in context and to provide a national perspective on trends in the delivery and funding of insured health services in Canada that are within the scope of the Act.
The statistical tables contain resource and cost data for insured hospital, physician and surgical-dental services by province and territory for five consecutive years ending on March 31, 2022. 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.
Information in the statistical tables is grouped according to the nine subcategories described below.
Registered Persons: Registered persons are the number of residents registered with the health care insurance plans of each province or territory.
Insured Hospital Services within Own Province or Territory: Statistics in this sub-section relate to the provision of insured hospital services to residents in each province or territory, as well as to visitors from other regions of Canada.
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: This represents 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: This represents residents’ medical costs incurred while travelling outside of Canada that are paid by their home province or territory.
Insured Surgical-Dental Services within Own Province or Territory: The information in this subsection describes insured surgical-dental services provided in each province or territory.
The Department of Health and Community Services (the department) is responsible for setting the overall strategic directions and priorities for the health and community services system throughout Newfoundland and Labrador.
The department works with stakeholders to develop and enhance policies, legislation, provincial standards, and strategies to support individuals, families, and communities to achieve optimal health and well-being. The department provides a lead role in policy, planning, program development, and support to the four Regional Health Authorities (RHAs). The department also works with stakeholders to ensure that high quality, cost effective, and timely health services are available for all Newfoundlanders and Labradorians.
The department provides leadership, coordination, monitoring, and support to the RHAs, which deliver the majority of publicly funded health services in the province, as well as to other entities that deliver programs and services. This ensures quality, efficiency, and effectiveness in areas such as the administration of health care facilities; access and clinical efficiency; mental health and addictions services; long-term care and community support services; health professional education and training programs; the control, possession, handling, keeping and sale of food and drugs; medical transportation; the preservation and promotion of health; the prevention and control of disease; and public health and the enforcement of public health standards.
With a net annual budget of approximately $3.22 billion, the department accounts for approximately 39 per cent of Newfoundland and Labrador's total budget. In Budget 2021-2022, funding was provided for various programs and initiatives to make significant improvements to mental health and addictions, home and community care, and primary health care. Included in this was $3.3 million to support virtual care service through the provincial 811 Healthline, which has become especially relevant in the context of the COVID-19 pandemic. The 2021-2022 budget also included an investment of $3.3 million to expand the Insulin Pump Program and $8.6 million to cover 14 new drugs under the Newfoundland and Labrador Prescription Drug Program. An overview of initiatives from the 2021-2022 Budget is available at the Government of Newfoundland and Labrador's website.
In Newfoundland and Labrador, health services are provided to more than 520,000 residents by approximately 33,700 people in the health and community services sector. Of this total, approximately 20,000 people are employed by the RHAs and approximately 224 people are employed by the department.
The purpose of this report is to clearly describe how Newfoundland and Labrador fulfilled the requirements of the Canada Health Act program criteria, conditions, and provisions in 2021-2022.
In response to the backlogs as a result of COVID-19, the RHAs implemented a number of strategies to reduce backlogs in outpatient settings across the province, including utilizing virtual care, providing access to primary health care through Non-Emergent Assessment Centres, providing public access to information through 811, utilizing nurse practitioners to support virtual access to primary care, and collaborating with community health to improve continuity of care.
Health care insurance plans managed by the department include the Medical Care Plan (MCP) and the Hospital Insurance Plan (HIP). Both plans are non-profit and publicly administered.
The Medical Care and Hospital Insurance Act came into force on October 1, 2016, replacing both the Medical Care Insurance Act, 1999, and the Hospital Insurance AgreementAct. The Medical Care and Hospital Insurance Act (the Act) can be viewed on the Newfoundland and Labrador House of Assembly website.
As per section 5 of the Act, the Minister of Health and Community Services is required to administer a plan of medical care and hospital insurance for residents of the province. The Act provides authority to make regulations defining who is a resident, prescribing which services are insured services, and under what circumstances insured services shall be paid by the Minister.
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 physicians for rendering insured professional services.
The HIP covers insured hospital services received within the province when recommended by a medical practitioner. Eligibility for coverage under the plan is linked with eligibility for the MCP. All beneficiaries of the MCP are automatically entitled to coverage under the HIP.
Both the HIP and the MCP operate in accordance with the provisions of the Medical Care and Hospital Insurance Act and related regulations, and in compliance with the Canada Health Act.
No legislative changes to health care insurance plan legislation or regulations were made in 2021-2022.
The department is mandated with administering the HIP and the MCP under section 5 of the Medical Care and Hospital Insurance Act. The department reports on these plans through the regular legislative processes, as well as through other public reporting mechanisms (e.g., Public Accounts and the Social Services Committee of the House of Assembly).
The Government of Newfoundland and Labrador has a provincial planning and reporting requirement for all government departments, including the Department of Health and Community Services. Under the Transparency and Accountability Act, the department and the 10 other entities that report to the Minister, including the Regional Health Authorities (RHAs), produce multi-year performance-based plans. Plans and reports are tabled in the House of Assembly and posted on the department's website.
The 2021-2022 Department of Health and Community Services annual report has been tabled in the House of Assembly and is available on the House of Assembly's website.
Each year, the province's Auditor General independently examines provincial Public Accounts. MCP expenditures are considered a part of the Public Accounts. While respecting privacy and personal information, the Auditor General has full and unrestricted access to code-based records of the MCP. There were no Auditor General reviews of the department's programs, services, or MCP expenditures in 2021–2022. The most recent comprehensive audit was a review of the Newfoundland and Labrador Prescription Drug Program in June 2015.
Specific program reviews are executed in accordance with the Office of the Auditor General plan, which is largely driven by risk. In the planning stages of an audit, the department would be notified by receipt of an engagement letter from the Office of the Auditor General, advising that an audit is being planned and requesting any necessary arrangements to execute it. An audit by the Auditor General did not occur in 2021-2022.
The four RHAs are subject to financial statement audits, reviews and compliance audits. Financial statement audits are performed by independent auditing firms that are selected by each RHA. Review engagements are conducted using the Generally Accepted Auditing Standards of the Canadian Institute of Chartered Accountants. Various compliance and physician audits are carried out by personnel from the department under the authority of the Medical Care and Hospital Insurance Act.
Physician records and professional medical corporation records are reviewed to ensure that the records support the services billed and that the services are insured under the MCP. Beneficiary audits are performed by personnel from the department under the Medical Care and Hospital Insurance Act.
As of March 31, 2022, the Medical Care and Hospital Insurance Act (the Act) and the Hospital Insurance Regulations provided for insured hospital services in Newfoundland and Labrador. No amendments were made to the Act during this current reporting period concerning insured hospital services. All the hospital services as defined under the Canada Health Act are insured services in Newfoundland and Labrador.
Insured hospital services are provided for in-patients and out-patients in 15 hospitals, 23 community health centres, and 68 community clinics throughout the province. As indicated in the statistics table, the change in the number of clinics in 2016-2017 reflects a change in how the department classifies public health facilities. Hospital insured services include:
There were no new services added to the schedule of insured hospital services during 2021-2022.
The coverage policy for insured hospital services is linked to the coverage policy for insured medical services. The department 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. Public consultation is not a requirement for de-listing a service.
Currently, Newfoundland and Labrador does not have any private diagnostic clinics that charge patients for services that would be considered insured if provided in a hospital.
As of March 31, 2022, the enabling legislation for insured physician services was the Medical Care and Hospital Insurance Act and the relevant regulations continued thereunder, which included the:
In 2021-2022 (as of March 31, 2022) there were 1,398 physicians (salaried and fee-for-service) active in practice in the province. For purposes of the Act, the following services are covered:
Administration of the influenza vaccine by physicians became temporarily billable under the Medical Care Plan (MCP) in October 2020. This measure remained in place throughout 2021-2022.
Physicians can choose not to participate in the health care insurance plan as outlined in section 8 of the Medical Care and Hospital Insurance Act, namely:
8. (3) A practitioner may, in writing, notify the minister of his or her election to collect payments in respect of insured services provided by the practitioner to beneficiaries otherwise than from the minister.
8. (4) An election under subsection (3) shall have effect from the first day of the first month beginning after the expiration of 60 days after the date on which the minister receives the notice of election.
8. (5) A practitioner who has made an election under subsection (3) may revoke the election by written notice to the minister.
8. (6) A revocation of election under subsection (5) shall have effect from the first day of the first month beginning after the expiration of 60 days after the date on which the minister receives the notice of revocation.
8. (7) Notwithstanding subsections (4) and (6), the minister may waive the time periods in those subsections where, in his or her opinion, it is reasonable to do so.
As of March 31, 2022, no physicians had opted out of the 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. Public consultation is not a specific requirement.
Medical goods and services that are implanted and associated with an insured service are provided free of charge to the patient and are consistent with national standards of practice. Patients retain the right to financially upgrade standard medical goods or services. Standards for medical goods are developed by the hospitals providing those services in consultation with service providers.
The 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 the MCP if the treatment is specified in the Surgical-Dental Services Schedule.
The Surgical Dental Program provides insured services under the Medical Care and Hospital Insurance Act. An insured service is defined as:
Policies on pre-existing conditions necessary to define 'medical necessity' must exist for the specific services to qualify as MCP insured services.
There were 13 dentists and oral surgeons providing insured services under the Surgical-Dental Program as of March 31, 2022.
Dentists and oral surgeons may opt out of the MCP as per section 8 of the Medical Care and Hospital Insurance Act referenced above. These dentists or oral surgeons must advise the patient of their opted-out status, state the fees expected and provide the patient with a written record of services and fees charged. As of March 31, 2022, there were no opted-out dentists or oral surgeons. There was no extra-billing in 2021-2022.
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.
Any addition of a surgical-dental service to the list of insured services must be approved by the Minister of Health and Community Services. There were no new services added to the list of insured surgical-dental services in 2021-2022.
Hospital services not covered include:
The use of the hospital setting for any services deemed uninsured by the MCP are also uninsured under the Hospital Insurance Plan. For purposes of the Medical Care and Hospital Insurance Act, the following is a list of uninsured physician services:
The Act provides the Lieutenant-Governor in Council the authority to make regulations prescribing which services are or are not insured services for the purpose of the Act. This would involve consultation with the Newfoundland and Labrador Medical Association and the Newfoundland and Labrador Dental Association. There is no specified requirement for public consultation when delisting a service. No services were de-listed from the MCP during 2021-2022.
Residents of Newfoundland and Labrador are eligible for coverage under the Medical Care and Hospital Insurance Act (the Act). This Act defines a "resident" as a person who is lawfully entitled to be or to remain in Canada, makes his or her home in the province, and is ordinarily present in the province, but does not include a tourist, transient, or visitor to the province.
The Medical Care Insurance Beneficiaries and Inquiries Regulations identify those residents eligible to receive coverage under the plans. There were no amendments to these Regulations during the reporting period. The Medical Care Plan (MCP) has established rules to ensure that the Regulations are applied consistently and fairly in processing applications for coverage. The 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. Under section 6 of the Act, every resident of the province is required to register for the MCP in accordance with the regulations. While there is no specified opt-out provision, a person may, in effect, do so by choosing not to register.
Persons not eligible for coverage under the MCP and Hospital Insurance Plan include:
If the status of these individuals change, they must meet the criteria as noted above in order to become eligible. Applicants wishing to appeal an eligibility issue may request a formal file review from the Minister of Health and Community Services.
There were approximately 528,143 people registered as active beneficiaries of the MCP as of March 31, 2022.
Foreign workers, international students, foreign clergy and dependants of North Atlantic Treaty Organization personnel and applicants for permanent residency are eligible for benefits. Returning Canadian citizens and their dependants born out-of-country, returning permanent residents who hold valid documentation, holders of Minister's permits, convention refugees, resettled refugees or "persons in need of protection" with valid immigration documents are also eligible, subject to MCP approval. Dependants of MCP beneficiaries may also be eligible for coverage.
On March 29, 2022, the department announced that Ukrainians entering the Newfoundland and Labrador under the Canada-Ukraine Authorization for Emergency Travel and the Special Family Reunification Sponsorship Pathway would be eligible for MCP registration for six month renewable periods, provided they remain a resident of the province.
Persons who meet the eligibility criteria who are 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 Armed Forces, and individuals released from federal penitentiaries. For coverage to be effective, registration is required under the Medical Care Plan (MCP). Immediate coverage is provided to persons from outside Canada authorized to work in the province for one year or more and their eligible dependants, and to international post-secondary students attending a recognized Newfoundland and Labrador educational institution who have a valid study permit entitling them to stay in Canada for more than 365 days and their eligible dependants. This requirement has been reduced to a six-month work permit for individuals entering the province under the Newfoundland and Labrador Provincial Nominee Program and the Atlantic Immigration Program. For international health care workers with employment authorizations, the period of employment may be for less than 365 days.
Newfoundland and Labrador is a party to the Interprovincial Agreement on Eligibility and Portability regarding matters pertaining to portability of insured services in Canada.
Sections 12 and 13 of the Hospital Insurance Regulations denote 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. No amendments to the Regulations were made in 2021-2022.
Coverage is provided to residents during temporary absences within Canada. The Government of Newfoundland and Labrador has entered into formal agreements (e.g., the Hospital Reciprocal Billing Agreement) with other provinces and territories for the reciprocal billing of insured hospital services. In-patient costs are paid at standard rates approved by the host province or territory. In-patient, high-cost procedures and out-patient services are payable based on national rates agreed to by provincial and territorial health plans through the Interprovincial Health Insurance Agreements Coordinating Committee.
Medical services incurred in all provinces (except Quebec) or territories are paid through the Medical Reciprocal Billing Agreement at host province or territory rates. Claims for medical services received in Quebec are submitted by the patient to the MCP for payment at host province rates.
In order to qualify for out-of-province coverage, a beneficiary must comply with the legislation and the MCP rules regarding residency in Newfoundland and Labrador. Generally, a resident must reside in the province for at least four months in each 12-month period to qualify as a beneficiary. International workers and students may qualify for out-of-province coverage of up to 182 days in a 365 day period. The rules regarding medical and hospital care coverage during absences include the following:
Failure to request out-of-province coverage or failure to abide by the residency rules may result in the resident having to pay for medical or hospital costs incurred outside the province.
Insured residents moving permanently to other parts of Canada are covered up to, and including, the last day of the second month following the month of departure.
No changes to coverage during temporary absences in Canada were made in 2021-2022.
Sections 12 and 13 of the Hospital Insurance Regulations denote portability of hospital coverage during absences both within and outside Canada. No amendments were made to the Regulations during the reporting period.
The province provides coverage to residents during temporary absences outside Canada. Out-of-country insured hospital in-patient and out-patient services are covered for emergencies, sudden illness, and elective procedures at established rates listed below. 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 MCP 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 haemodialysis is $220 per treatment. The approved rates are paid in Canadian funds.
Physician services are covered for emergencies or sudden illness, and are also insured for elective services not available in the province or within Canada. Emergency physician services are paid at the same rate as would be paid in Newfoundland and Labrador for the same service. If the elective services are not available in Newfoundland and Labrador, they are usually paid at Ontario rates, or at rates that apply in the province where they are available.
Coverage is immediately discontinued when residents move permanently to other countries.
Prior approval is not required for medically necessary insured services provided by accredited hospitals or licensed physicians in the other provinces and territories that are billed reciprocally. 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 care outside the country because the insured service is not available in Canada. The referring physician must contact the department for prior approval. If prior approval is granted, the provincial health care insurance plan will pay the costs of insured services necessary for the patient's care at host country rates. Prior approval is not granted for out-of-country treatment or elective services at host country rates if the service is available in the province or elsewhere within Canada. If an individual opts to receive the service outside Canada it will be covered at the provincial rate if available in Newfoundland and Labrador. If the service is not available in Newfoundland and Labrador, it is usually paid at Ontario rates, or at rates that apply in the province where they are available. Applicants wishing to appeal out-of-province coverage may request a formal file review by the Minister.
Access to insured health services in Newfoundland and Labrador is provided on uniform terms and conditions. Co-insurance charges for insured hospital services and extra-billing by physicians is prohibited in the province.
Section 7 of the Medical Care and Hospital Insurance Act (the Act) outlines that a practitioner who provides insured services, whether or not he or she has made an election to opt out of participation in the Medical Care Plan (MCP), shall not charge or collect from a beneficiary a fee for those insured services in excess of the amount payable under the Act and regulations. A practitioner or other person who contravenes this is guilty of an offence and liable on summary conviction to a fine of up to but not more than $20,000 for each contravention. Cases of extra-billing and user charges may be identified through the audit process described under section 21 of the Act or may be reported from residents. These instances may be discovered when residents submit claims to the department for reimbursement.
Complaints from residents regarding charges for insured health services are managed by the department. Depending on the circumstance, the department may investigate or refer the matter to the College of Physicians and Surgeons of Newfoundland and Labrador, the regulatory body for physicians in the province, for potential disciplinary action. Residents may also contact the College directly if they feel that they have been subject to improper billing by their physician.
Regarding repayment, section 25 of the Act provides the Minister with powers to recover overpayments and interest that were discovered via audit. The Minister of Health and Community Services may do this by entering into an agreement with the practitioner or their professional corporation or the Minister may order the practitioner to pay to the Minister the overpaid amount plus interest.
Residents wishing to file a complaint regarding medical care that they have received are encouraged to call or email the Complaints Coordinator at the College (1-709-726-8546 or [email protected]) or call the MCP general inquiries line (Avalon area: 1-866-449-4459; all other regions:1-800-563-1557).
The department works closely with post-secondary educational institutions within the province to maintain an appropriate supply of health professionals. The province also works with external organizations for health professionals not trained in this province. Targeted recruitment incentives are in place to attract health professionals. Several programs have been established to provide targeted sign-on bonuses, bursaries, opportunities for upgrading, and other incentives for a wide variety of health occupations.
With respect to wait times to access insured health services, the department introduced the Policy for Provision of Cataract Surgery in Non-Hospital Designated Facilities in 2020-2021. By extending the provision of cataract surgeries to include non-hospital facilities, the department aims to increase patient access to cataract surgery and reduce wait times overall. In 2021-2022 there were 3,500 cataract procedures approved/delivered by non-hospital facilities.
Physicians in the province are paid via fee-for-service, salary or alternate payment plan. As of March 31, 2022, the legislation governing payments to physicians and dentists for insured services continues to be the Medical Care and Hospital Insurance Act. There is no legislation that speaks to the ability of physicians or dentists to levy block fees. The Newfoundland and Labrador Medical Association (NLMA) has published the Physicians’ Guide to Non-Insured Services, which provides guidance on third party requested services, other non-insured services, suggested fees and relevant policies.
Compensation agreements are negotiated between the government and the NLMA, on behalf of physicians, and the Newfoundland and Labrador Dental Association (NLDA) on behalf of dentists. A Memorandum of Agreement was reached with the NLMA in December 2021. The link to the MOA can be found on the department's website. The current agreement with the NLDA expires on March 31, 2022 and was negotiated and renewed for a four-year term (2022-2026). The signed agreements can also be found online on the department's website.
The Act authorizes the Minister to appoint auditors to audit the accounts and claims for payment submitted by physicians and dentists. The Act prescribes the power and duties of auditors, sets out the remedies available and details the processes to be followed. The Act also details the review and appeal processes available to practitioners.
The department is responsible for funding Regional Health Authority (RHA) space for ongoing hospital operations and capital acquisitions. Payments are made in accordance with the Medical Care and Hospital Insurance Act, the Regional Health Authorities Act and the Financial Administration Act. As part of their accountability to the department, the RHAs are required to meet the department's annual reporting requirements, which include submitting an annual budget, pursuant to section 21 of the Regional Health Authorities Act, as well as audited financial statements and other financial and statistical information throughout the year as required.
Funding provided by the federal government through the Canada Health Transfer and the Canada Social Transfer 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 2021–2022, these documents include the Public Accounts and Estimates 2021–2022. The Public Accounts and Estimates, tabled by the Government in the House of Assembly, are publicly available and are shared with Health Canada for information purposes.
not applicable
not applicable
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Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.
Return to footnote 1 referrer
Excludes inactive physicians.Total salaried and fee-for-service.
Return to footnote 2 referrer
Rounded to the nearest thousand.
Return to footnote 3 referrer
The claims in NL's data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.
Return to footnote 4 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
Return to footnote 5 referrer
In Prince Edward Island (PEI) the Department of Health and Wellness is responsible for providing policy, strategic, and fiscal leadership for the health care system.
Health Services Act, R.S.P.E.I. 1988, Cap. H-1.6 provides the regulatory and administrative frameworks for improvements to the health care system in PEI by:
Within this governance structure Health PEI has the responsibility to:
The Hospital Services Insurance Plan, under the authority of the Minister of Health and Wellness (the Minister), is the vehicle for delivering hospital care insurance in Prince Edward Island (PEI). The enabling legislation is the Hospital and Diagnostic Services Insurance Act R.S.P.E.I. 1988, Cap. H-8. The Medical Services Insurance Plan provides for insured physician services under the authority of the Health Services Payment Act R.S.P.E.I. 1988, Cap. H-2. Together, the plans insure services as defined under section 2 of the Canada Health Act. The Department of Health and Wellness (the Department) is responsible for providing policy, strategic, and fiscal leadership for the health care system, while Health PEI is responsible for service delivery and the operation of hospitals, health centres, manors and mental health facilities. Health PEI is responsible for the hiring of physicians, while the Public Service Commission of PEI hires nurse practitioners, nurses and all other health related workers.
An annual report is submitted by the Department to the Minister 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. The Health PEI annual report for 2021-2022 has not yet been published.
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.
The provincial Auditor General conducts annual audits of the public accounts of PEI. The public accounts of the province include the financial activities, revenues and expenditures of the Department of Health and Wellness.
The provincial Auditor General, through the Audit Act, R.S.P.E.I. 1988, c A-24, has the discretion to conduct further audit reviews on a comprehensive or program specific basis.
Insured hospital services are provided under the Hospital and Diagnostic Services Insurance Act. The accompanying Regulations define the insured in-patient and out-patient hospital services available at no charge to a person who is eligible. Insured hospital services include, but are not limited to:
The process to add a new hospital service to the list of insured services involves extensive consultation and negotiation between the Department of Health and Wellness (the Department), Health PEI and key stakeholders. The process involves the development of a business plan which, when approved by the Minister of Health and Wellness, would be taken to Treasury Board for funding approval. Executive Council (Cabinet) has the final authority in adding new services.
The enabling legislation that provides for insured physician services is the Health Services Payment Act. Insured physician services are provided by medical practitioners licensed by the College of Physicians and Surgeons. The total number of practicing practitioners who billed the Medical Services Insurance Plan as of March 31,2022, was 462. This includes all physicians (complement, locums, visiting specialists, and other non-complement physicians). Under section 10 of the Health Services Payment Act, a physician or practitioner who is not a participant in the Medical Services Insurance Plan is not eligible to bill the Plan for services rendered. When a non-participating physician provides a medically required service, section 10(2) requires that physicians advise patients that they are non-participating physicians or practitioners and provide the patient with sufficient information to enable recovery of the cost of services from the Department. Under section 10.1 of the Health Services Payment Act, a participating physician or practitioner may determine, subject to and in accordance with the Regulations and in respect of a particular patient or a particular basic health service, to collect fees outside the Plan or selectively opt out of the Plan. Before the service is rendered, patients must be informed that they will be billed directly for the service. Where practitioners have made that determination, they are required to inform the Minister thereof and the total charge is made to the patient for the service rendered.
As of March 31, 2022, no physicians had opted out of the Medical Services Insurance Plan.
All basic health services rendered by physicians that are medically required are covered by the Medical Services Insurance Plan. These include:
Services that are not covered as insured benefits include:
The process to add a physician service to the list of insured services involves negotiation between the Department, Health PEI, and the Medical Society of Prince Edward Island (PEI). The process involves development of a business plan which, when approved by the Minister, would be taken to Treasury Board for funding approval. Insured physician services may also be added or deleted as part of the negotiation of a new Master Agreement with the Medical Society of PEI (section 5.2). Cabinet has the final authority in adding new services.
Most dental services are not insured under the Medical Services Insurance Plan. Only oral maxillofacial surgeons are paid through the Plan. There are currently three 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.
Any new surgical-dental services added to the list of insured services covered by the Medical Services Insurance Plan is done through negotiations of the Dental Agreement between the Department, Health PEI, and the Dental Association of PEI. In 2021–2022, no new services were added to the Dental Agreement.
Services not covered by the Medical Services Insurance Plan include:
Hospital services not covered by the Hospital Services Insurance Plan include:
The process to de-insure services covered by the Medical Services Insurance Plan is done in collaboration with the Department, Health PEI, and the Medical Society of PEI. No services were de-insured during the 2021–2022 fiscal year.
All Prince Edward Island residents have equal access to services. Third parties such as private insurers or the Workers’ Compensation Board of PEI do not receive priority access to services through additional payment.
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.
The Health Services Payment Act and the Hospital and Diagnostic Services Insurance Act, define eligibility for the Medical Services Insurance Plan and the Hospital Services Insurance Plan respectively. These plans are designed to provide coverage for eligible Prince Edward Island (PEI) residents. A resident is anyone legally entitled to remain in Canada and who makes his or her home and is ordinarily present on an annual basis for at least six months plus a day in PEI. While there is no formal appeal process, an individual can seek clarification regarding their eligibility determination.
All new residents must register with Health PEI in order to become eligible. Persons who establish permanent residence in PEI from elsewhere in Canada will become eligible for insured hospital and medical services on the first day of the third month following the month of arrival. PEI currently does not have a process where a resident can opt out of the health care insurance plan.
Residents who are ineligible for insured hospital and medical services coverage in PEI are those who are eligible for certain services under other federal or provincial government programs, such as members of the Canadian Forces, inmates of federal penitentiaries, and clients of Workers’ Compensation or the Department of Veterans Affairs’ programs.
Ineligible residents may become eligible in certain circumstances. For example, members of the Canadian Forces become eligible on discharge or completion of rehabilitative leave. Penitentiary inmates become eligible upon release. In such cases, the province where the individual in question was stationed at the time of discharge or release, or release from rehabilitative leave, would provide initial coverage during the customary waiting period of up to three months. Parolees from penitentiaries will be treated in the same manner as discharged prisoners.
New or returning residents must apply for health coverage by completing a registration application from Health PEI. 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 of becoming eligible. 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 and the Health Services Insurance Plan in PEI as of March 31, 2022, was 157,157.
Foreign students, tourists, transients, or visitors to PEI do not qualify as residents of the province and are, therefore, not eligible for hospital and medical insurance benefits.
Temporary workers, refugees, and Minister's Permit holders are not eligible for hospital and medical insurance benefits.
Insured persons who move to Prince Edward Island (PEI) from another province or territory in Canada are eligible for health insurance on the first day of the third month following the month of arrival in the province.
Residents absent each year for any reasons must reside in PEI for at least six months plus a day each year in order to be eligible for sudden illness and emergency services while absent from the province, as allowed under section 11 of the Health Services Payment Act Regulations. A person, including a student, who is temporarily absent from the province for up to 182 days in a 12 month period must notify Health PEI before leaving.
PEI participates in the Hospital Reciprocal Billing Agreements and the Medical Reciprocal Billing Agreements along with other jurisdictions across Canada.
The Health Services Payment Act is the enabling legislation that defines portability of health insurance during temporary absences outside of Canada, as allowed under section 11 of the regulations thereunder.
Persons must reside in PEI for at least six months plus a day each year in order to be eligible for sudden illness and emergency services while absent from the province, as allowed under section 11 of the Health Services Payment Act Regulations.
Insured residents may be temporarily out of the country for up to a 12 month period in some circumstances.
Students attending a recognized learning institution in another country must provide proof of enrollment from the educational institution on an annual basis. Students must notify Health PEI upon returning from outside the country.
For PEI residents leaving the country for work purposes for longer than one year, coverage ends the day the person leaves.
For PEI residents travelling outside Canada, coverage for emergency or sudden illness will be provided at PEI rates only, in Canadian currency. Residents are responsible for paying the difference between the full amount charged and the amount paid by Health PEI.
Prior approval is required from Health PEI before receiving non-emergency, out-of-province medical or hospital services. Island residents seeking such required services may apply for prior approval through a PEI physician. If approval is not granted, a letter can be submitted to Health PEI to appeal a medical insurance decision. Full coverage may be provided for (PEI insured) non-emergency or elective services, provided the physician completes an application to Health PEI. Prior approval is required from the Medical Director of Health PEI to receive out-of-country hospital or medical services not available in Canada.
Both of Prince Edward Island's (PEI) Hospital Services Insurance Plan and the Medical Services Insurance Plan provide services on uniform terms and conditions on a basis that does not impede or preclude reasonable access to those services by insured persons. While there is no formal complaints process for inappropriate charges, an individual can seek clarification on the appropriateness of any charges through the Department of Health and Wellness (the Department). The Department can be contacted at:
Prince Edward Island Department of Health and Wellness P.O. Box 2000 Charlottetown, PE C1A 7N8 (902) 368-6414
PEI has a publicly administered and funded health system that guarantees universal access to medically necessary hospital and physician services as required by the Canada Health Act.
The Government of PEI recognizes that the health system must constantly adapt and expand to meet the needs of residents.
Several examples of initiatives from the 2021–2022 fiscal year include:
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 last five-year Master Agreement between the Medical Society of PEI, the Department and Health PEI covered the period of April 1, 2019, to March 31, 2024.
Many physicians continue to work on a fee-for-service basis; however, alternate payment plans have been developed and some physicians receive salary, contract and sessional payments. Alternate payment modalities are expanding and seem to be the preference for new graduates. Currently, 69 per cent of PEI's physicians (excluding locums and visiting specialists) are compensated under an alternate payment method (non-fee-for-service) as their primary means of remuneration.
The legislation governing payments to physicians and dentists for insured services is the Health Services Payment Act. Health PEI is responsible for auditing physician claims for compliance with legislative requirements and the Master Agreement tariff, as permitted under the Health Services Payment Act and delegated by the Minister. The Health Services
Payment Act allows for audits of physician payments to assist in efficient and effective use of resources. Health PEI's audit rights are affirmed in the Master Agreement with the Medical Society of PEI. Health PEI approved its Practitioner Claims Monitoring, Compliance, and Recovery Policy on December 22, 2015, and continues to conduct physician payment audits on a go-forward basis. The policy information was communicated to physicians in January 2016.
Physicians submit bills for services provided to insured residents to Health PEI's Claims Payment System (CPS). The CPS contains billing rules aligned with the Master Agreement which help to ensure billings which do not meet Master Agreement criteria are rejected or flagged for review. As part of Health PEI's monitoring process, physicians are randomly selected and requested to provide Health PEI with documentation to support sample billings. Overall physician billings are periodically reviewed to identify unusual billing profiles when compared to peers, significant increases in fee code billings and irregularities in the use of new fee codes. Any irregularities discovered may trigger an audit.
The audits include specific steps for:
The Health Services Payment Act allows for recovery of overpayments and provides for appeal of adjustments to claims. The initial stage for appeal is a discussion with the Executive Director, Medical Affairs or designate. If no agreement can be reached, the matter is appealed to the Health Services Payment Advisory Committee which will provide a recommendation to the Minister.
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.
The Government of Prince Edward Island (PEI) 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 2021–2022 Annual Budget and in the 2021–2022 Public Accounts, both of which 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 the 2021–2022 Annual Report.
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.
Prince Edward Island Table 16 Footnote 1 referrer
The Nova Scotia Department of Health and Wellness (the Department) vision and mission are:
Vision: Healthy Nova Scotians
Mission: To lead a quality, equitable and sustainable health care system that inspires and promotes the health and well-being of all people in Nova Scotia
The health and wellness system includes the delivery of health care as well as the prevention of disease and injury and the promotion of health and healthy living. The Health Authorities Act establishes roles and responsibilities of the Department, the Nova Scotia Health Authority, and the IWK Health Centre.
The Department is responsible for providing leadership and ensuring accountability for funding for the health system. The Department includes the Office of Addictions and Mental Health and the Office of Healthcare Professional Recruitment and continues to work along aside the Department of Seniors and Long-term Care.
The Nova Scotia Health Authority (NSHA) and the IWK Health Centre are responsible for governing, managing, and providing health services in the province and engaging with the communities they serve.
Insured services in Nova Scotia cover hospital services and physician services. Services such as home care, long-term care, and pharmaceuticals are also provided.
Nova Scotia continues to be committed to the delivery of hospital services and medically required 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.
As Nova Scotians learn to live with COVID-19, Nova Scotia has continued to work with health system partners to ensure the needs of Nova Scotians are met. Despite the ongoing challenges of the pandemic, Nova Scotia, including the NSHA and the IWK, worked closely with community partners to advance health priorities including primary care, continuing care, public health, and mental health and addictions.
Specific measures to combat the backlogs in the healthcare system, as a result of the COVID-19 pandemic in 2021-2022, include:
Two plans cover insured health services in Nova Scotia: The Hospital Insurance and the Medical Services Insurance (MSI) Plans, which both operate under the Health Services and Insurance Act.
The Department administers the Hospital Insurance Plan and the MSI Plan is administered and operated by Medavie Blue Cross (MBC) on behalf of the Minister of Health and Wellness (the Minister).
Section 8 of the Health Services and Insurance Act gives the Minister, with approval of the Governor in Council, the power to enter into agreements and vary, amend or terminate the same agreements with such person or persons as the Minister deems necessary to establish, implement, and carry out the MSI Plan.
The Department and MBC entered into a service level agreement, effective August 1, 2005. Under the agreement, MBC is responsible for operating and administering programs contained under MSI, Pharmacare Programs and Health Card Registration Services. In June 2021, Nova Scotia finalized new contracts with Medavie Blue Cross to administer the province's Medical Services Insurance (MSI) and other programs. Under the contracts, Medavie will administer the prescription monitoring program, provincial health card program, payments to physicians, pharmacare programs and ancillary programs such as optometry and prosthetics.
In 2021-2022, no amendments were made to either the Health Services and Insurance Act or the Medical Services Insurance Regulations.
A. Hospital Insurance
Section 17(1)(i) of the Health Services and Insurance Act, and sections 11(1) and 12(1) of the Hospital Insurance Regulations, under this Act, set out the terms for reporting by hospitals and hospital boards to the Minister of Health and Wellness.
B. Medical Insurance
In the service level agreement between MBC and the Department, MBC is obliged to provide reports to the Department under various Statements of Requirements as listed in the contract. MBC is audited every year on various areas of reporting. MBC provides audited financial statements for the fiscal year ending March 31st and the statements are provided within 4 months of the fiscal year end.
The Auditor General audits the provincial financial statements. Under its service level agreement with the Department, MBC provides audited financial statements of MSI costs to the Department. The Auditor General and the Department have the right to perform audits of the administration of the agreement with MBC.
Within the Physician Services portfolio there are various programs that are audited by third parties that submit financial statements to the Department. This includes financial statements from the Dalhousie Family Medicine training sites and the Practice Ready Assessment program. Additionally, MBC conducts audits of the Academic Funding Plans (AFP).
On behalf of the Minister, the service provider that operates Nova Scotia's out-of-hospital emergency medical services (Emergency Health Services [EHS] 911 Ground Ambulance, EHS Critical Care Transport, and non-emergent EHS Mobile Integrated Health Services) and 811 Telehealth services is required to submit audited financial statements each year and they are due 90 days after March 31st. The Department also receives audited financial statements from various other service providers including Nova Scotia Hearing and Speech Centres and Canadian Blood Services, but there is no set deadline for these statements
Under section 36(4) of the Health Authorities Act, a health authority is required to submit to the Minister, no later than June 30 each year, an audited financial statement for the preceding fiscal year.
In addition to the annual audit of the Provincial Financial Statements, the Auditor General conducts performance audits on a variety of programs. The most recent Auditor General audits on the Department of Health and Wellness were follow-up reports, specifically:
For further details please visit the Office of the Auditor General of Nova Scotia's website.
MBC administers monies to pay physician accounts as per the service agreement with the Department. Physician rates of pay are set based on the Master Agreement negotiated with Doctors Nova Scotia (the sole negotiating body for physicians in Nova Scotia) and the Clinical Academic Funding Plan, which is negotiated with Doctors Nova Scotia, Dalhousie University, the Nova Scotia Health Authority, and the IWK Health Centre.
MSI is the provincial plan of insured medical services. It is designed to pay for a wide range of medically necessary physicians’ services, as well as certain dental and optometric services.
The Department and the Office of the Auditor General, have the right, under the terms of the service level agreement with MBC, to audit all MSI and Pharmacare transactions.
Green Shield Canada administers and has the authority to receive monies to pay dentists under a service level agreement with the Department. The tariff of dental fees is negotiated between the Nova Scotia Dental Association and the Department.
As part of an agreement with the Department, Green Shield Canada also provides monthly, quarterly and annual reports with regard to dental programs in Nova Scotia. This includes hospital dental services when the hospital setting is required for the safe performance of the procedure. These reports address provider claims and payment, program utilization, and audit. A complete list of reports can be obtained from the Department.
MBC is responsible for providing a number of regular and ad hoc reports to the Department pertaining to health card administration, physician claims activity, financial monitoring, provider management, audit activities, and program utilization. These reports are submitted on a monthly, quarterly, or annual basis. A complete list of reports can be obtained from the Department.
The enabling legislation that provides for insured hospital services in Nova Scotia is the Health Services and Insurance Act (HSIA). Hospital Insurance Regulations are made pursuant to the Act. No amendments were made to this legislation in fiscal year 2021-2022.
Under the Hospital Services Insurance Plan, in-patient services include:
Out-patient services include:
Each year, the Nova Scotia Health Authority and the IWK Health Centre submit business plans outlining budgets and priorities for the coming year to ensure safe and high-quality access to care. Under the Health Authorities Act, business plans are to be submitted on November 1st every year and are approved by the Minister.
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. No amendments were made to this legislation in 2021-2022.
As of March 31, 2022, 2,906 physicians were paid through the Medical Services Insurance (MSI) Plan.
Physicians retain the ability to opt in or out of the MSI Plan. To opt out, a physician notifies MSI and relinquishes their billing number. MSI reimburses patients who pay the physician directly due to opting out. As of March 31, 2022, no physicians had opted-out of the MSI plan to pursue this method of remuneration.
Insured services include those that are medically necessary. Payment is provided for the following physicians’ services, when medically necessary:
If, in the opinion of the physician, a patient requires the services of a specialist for either consultation or care, a referral to the specialist is made. Payment at the specialist tariff is based on a valid referral by the attending physician.
In 2020–2021, Nova Scotia expanded virtual care to allow physicians to bill for insured non-procedural services provided over the phone or another virtual platform. Virtual care sevices can currently be billed until March 31, 2023.
The Fee Committee is outlined in article 4.1(c) of the 2019 Master Agreement. The Fee Committee is a collaborative structure made up of the Department, Nova Scotia Health Authority, and Doctors Nova Scotia. The Committee reviews requests for new fees, amendments to current fees, and for additions, revision, or clarification of the Preamble to the MSI Physician manual. The Fee Committee provides advice and recommendations to the Master Agreement Management Group on all matters pertaining to the fee schedule, based on consensus and available budget. If the fee is approved, Medavie Blue Cross (MBC) is directed to add the new fee to the schedule of insured services payable by the MSI Plan.
Public consultations are not generally undertaken when listing or delisting insured medical services.
To provide insured surgical-dental services under the Health Services and Insurance Act, dentists must be registered members of the Nova Scotia Dental Association, must be certified competent in the practice of dental surgery, and must also have privileges from the health authorities to deliver services at specific hospitals. The Health Services and Insurance Act provides that a dentist may choose not to participate in the MSI Plan. To participate, a dentist must register with MSI. A participating dentist who chooses not to participate must advise MSI in writing and is then no longer eligible to submit claims to MSI. In 2021–2022, 18 dentists were paid through the MSI Plan for providing insured surgical-dental services.
Insured surgical-dental services must be provided in a public health care facility, are detailed in the Department Dentists Guide, and are reviewed annually. Services under this program are insured when the condition of the patient is such that it is medically necessary for the procedure to be done in a public hospital and the procedure is of a surgical nature.
Generally included as insured surgical-dental services are extractions and oral and maxillofacial surgery. Requests for an addition to the list of surgical-dental services are accomplished through the Nova Scotia Dental Association, which submits a proposal to the Department. In consultation with experts in the field, the Department renders a decision on the addition of the procedure as an insured service. Public consultations are not undertaken during the consideration of additions to the list of insured services.
Insured services in the "other extraction services" (routine extractions) category are approved for the following groups of patients: cardiac patients, transplant patients, immunocompromised patients, and radiation patients. This is the case only when patients are undergoing active treatment in a hospital setting and the medical procedure must require the removal of teeth in a manner that would otherwise be considered routine extractions.
Currently, there are no opted-out dentists and no non-participating dentists providing insured surgical-dental services.
Uninsured hospital services include:
Uninsured Physician Services include:
Major third-party agencies currently purchasing medically required health services in Nova Scotia include Workers’ Compensation Board and the Department of National Defence.
All residents of the province are entitled to services covered under the Health Services and Insurance Act. If enhanced goods and services, such as fibreglass casts, are offered as an alternative, the specialist or physician is responsible to ensure that the patient is aware of their responsibility for the cost. Patients are not denied service based on their inability to pay. The province provides alternatives to any of the enhanced goods and services.
The Department carefully reviews all patient complaints or public concerns that may indicate that the general principles of insured services are not being followed.
If a service or procedure is deemed by the Department not to be medically required, it is removed from the physician fee schedule and will no longer be reimbursed to physicians as an insured service. Once a service has been de-insured, all procedures and testing relating to the provision of that service also become de-insured. The same also applies to dental services and hospital services. Public consultations are not undertaken during the determination of medical necessity and de-listing of insured services. Consultation with the Nova Scotia Dental Association has preceded past de-listing of dental services. The last time there was any significant de-insurance of services was in 1997.
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 their home and is ordinarily present in Nova Scotia. Registration for the hospital and medical insurance plans is voluntary and residents may choose not to register.
In 2021-2022, a person was considered to be "ordinarily present" in Nova Scotia if the person:
Children born out-of-country to Nova Scotia residents are eligible for coverage provided their parents meet the Nova Scotia residency requirements.
Persons moving to Nova Scotia from another Canadian province will normally be eligible for Medical Services Insurance 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 IRCC.
Individuals insured under the Workers’ Compensation Act, or any other act of the Legislature or of the Parliament of Canada, or under any statute or law of any other jurisdiction either within or outside of Canada, are not eligible for Medical Services Commission (MSI) Coverage (such as members of the Canadian Forces, federal inmates and some classes of refugees). Once individuals are no longer covered under any of the acts, statutes or laws noted above, they are then eligible to apply for and receive Nova Scotia health insurance coverage, provided that they are either a Canadian Citizen, a permanent resident as defined by IRCC, or meet the Nova Scotia residency requirements. An administrative review may be requested for individuals who are deemed ineligible.
In 2021-2022, the total number of residents registered with the health insurance plan was 1,079,880.
No amendments were made to the Nova Scotia Health Insurance Policy in 2021-2022.
Other individuals may be eligible for insured health care services in Nova Scotia if they meet specific eligibility criteria listed below:
Immigrants: Persons moving from another country to live permanently in Nova Scotia are eligible for health care on the date of arrival if they arrive as a permanent resident, as determined by IRCC.
Non-Canadians married to Canadian Citizens or Permanent Residents (copy of marriage certificate required), who possess the required documentation from IRCC indicating they have applied for permanent residency, will be eligible for coverage on the date of arrival in Nova Scotia (if applied prior to their arrival to Nova Scotia), or the date of application for permanent residency (if applied after their arrival in Nova Scotia).
Convention refugees or persons in need of protection who possess the required documentation from IRCC indicating they have applied for permanent residency will be eligible for coverage on the date of application for permanent residency.
In 2021-2022, there were 66,281 Permanent Residents registered with the health care insurance plan.
Refugees: Refugees are eligible for Medical Services Insurance (MSI) once they have been granted permanent residency status by IRCC, or if they possess either a work permit or study permit.
Work Permits: Persons moving to Nova Scotia from outside the country who possess a work permit can apply for coverage on the date of arrival in Nova Scotia, provided they will be remaining in Nova Scotia for at least one full year. A declaration must be signed to confirm that the worker will not be outside Nova Scotia for more than 31 consecutive days, unless required in the course of employment. MSI coverage is extended for a maximum of 12 months at a time. Each year, a copy of their renewed immigration document must be presented, and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, are granted coverage on the same basis. Seasonal Workers are eligible for the same coverage as those with work permits.
Once coverage has terminated, the person is to be treated as never having qualified for health services coverage as herein provided and must comply with the above requirements before coverage will be extended to them or their dependants.
In 2021-2022, there were 12,131 individuals with work permits covered under the health care insurance plan.
Study Permits: Persons moving to Nova Scotia from another country and who possess a study permit (Student Authorization) will be eligible for MSI on the first day of the thirteenth month following the month of their arrival, provided they have not been absent from Nova Scotia for more than 31 consecutive days, unless required in the course of their studies. MSI coverage is extended for a maximum of 12 months at a time and only for services received within Nova Scotia. Each year, a copy of their renewed immigration document must be presented, and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, will be granted coverage on the same basis once the student has gained entitlement.
In 2021-2022, there were 1,936 individuals with study permits covered under the health care insurance plan.
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. The waiting period is waived for families of Canadian Armed Forces moving to Nova Scotia
The Interprovincial Agreement on Eligibility and Portability is followed in all matters pertaining to the portability of insured services.
Generally, the Nova Scotia Medical Services Insurance 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 studies at an educational institution may remain eligible for MSI on a yearly basis. To qualify for MSI, the student must provide to MSI a letter directly from the educational institution which states that they are registered as a full-time student. MSI coverage will be extended on a yearly basis pending receipt of this letter.
Workers who leave Nova Scotia to seek employment elsewhere will still be covered by MSI for up to 12 months, provided they do not establish residence in another province or territory. Services provided to Nova Scotia residents in other provinces or territories are covered by reciprocal agreements. Nova Scotia participates in the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement. Quebec is the only province that does not participate in the Medical Reciprocal Billing 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. Nova Scotia pays the host province rates for insured services in all reciprocal billing situations.
The total amount paid by the plan in 2021-2022 for in-patient and out-patient hospital services received in other provinces and territories was $22,337,476.
Nova Scotia residents remain eligible to receive MSI during vacation outside of the province for up to seven months in each calendar year and will continue to be deemed a resident if the following conditions are met:
No amendments were made to the Eligibility for Nova Scotia Health Insurance Programs Policy in 2021-2022.
Nova Scotia adheres to the Agreement on Eligibility and Portability for dealing with insured services for residents temporarily outside Canada. Provided a Nova Scotia resident meets eligibility requirements, out-of-country services will be paid, at a minimum, on the basis of the amount that would have been paid by Nova Scotia for similar services rendered in this province. In order to be covered, procedures of a non-emergency nature must have prior approval before they will be covered by MSI.
Residents receiving haemodialysis outside Canada are eligible for reimbursement to a maximum of $496 per day, provided they submit the original service invoice.
Nova Scotia residents remain eligible to receive MSI during vacation out-of-country for up to seven months in each calendar year and continue to be deemed a resident if the above stated conditions are met.
Students and their dependants who are temporarily absent from Nova Scotia and in 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 volunteering, missionary work, or research) outside Canada, which does not exceed 24 months, are still covered by MSI, providing the person has already met the residency requirements.
The total amount spent in 2021-2022 for insured in-patient services provided outside of Canada was $5,036,502. Nova Scotia does not cover out-patient services out-of-country.
In 2021-2022, the total number of residents registered with the health insurance plan was 1,079,880.
No amendments were made to the Eligibility for Nova Scotia Health Insurance Program Policy in 2021-2022.
Prior approval must be obtained, if residents wish to be reimbursed for elective services outside the country. Application for prior approval is made to the medical consultant 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. An administrative review may be requested for individuals who are deemed ineligible.
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 upon 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. In Nova Scotia, there is not a dedicated number or website to report cases of patient charges.
Complaints generally come directly to the Department of Health and Wellness via telephone or e-mail; are received by Medavie Blue Cross and then directed to the Department; or are directed to the College of Physicians and Surgeons of Nova Scotia. Complaints are investigated and addressed.
The Department of Health and Wellness General Inquiry contact information is as follows: By phone: 902-424-5818 1-800-387-6665 (toll-free in Nova Scotia) 1-800-670-8888 (TTY/TDD) By mail: Department of Health and Wellness P.O. Box 488 Halifax, Nova Scotia B3J 2R8 Secure form: https://novascotia.ca/dhw/about/contact/#form
Nova Scotia continually monitors and reviews situations around access to insured health services across Canada to ensure equity of access.
The Health Services and Insurance Act, RS chapter 197 governs payment to physicians and dentists for insured services. Physician payments are made in accordance with a negotiated agreement between Doctors Nova Scotia (the sole bargaining agent for physicians) and the Province of Nova Scotia, as represented by the Minister.
Fee-for-service is the largest single funding source of payment for physician services; however, there is growth in the share of total physician payments made through alternative payment arrangements. Alternative payment arrangements facilitate the delivery of medical care that may not be compatible with the fee-for-service funding model and are often used to support physician recruitment and retention, and the funding of group-based care in rural areas where service volumes are expected to be less. Additionally, within the academic funding context, payments may include compensation for non-medical activities such as teaching, research, and administration.
The 2019 Master Agreement committed the province to developing a blended capitation model; the blended capitation funding model pilot project launched in Summer 2022 and is underway. Other funding programs such as emergency agreements, sessional funding, and locum funding are also utilized by the province.
In Nova Scotia, payment and payment monitoring are part of Medical Services Insurance's (MSI) deliverables. Section 9 of the 2019 Master Agreement lays out the Department's right to conduct audits of physicians with respect to insured medical service being claimed. Schedule E of the Master Agreement outlines billing audit processes including an Audit Committee of the Master Agreement Management Group to review the audit process and make recommendations. Annually, MSI develops an audit plan and conducts monitoring of claims to determine whether:
Payment rates for dental services in the province are negotiated between the Department and the Nova Scotia Dental Association following a process similar to physician negotiations. Dentists are generally paid on a fee-for-service basis. Pediatric dentists at the IWK Health Centre receive remuneration through an Academic Funding Plan.
The Department establishes budget targets for health care services. It does this by receiving business plans from the Nova Scotia Health Authority and the IWK Health Centre and other non-district health authority organizations. Approved provincial estimates form the basis on which payments are made to these organizations for service delivery.
The Health Authorities Act establishes the Nova Scotia Health Authority and the IWK Health Centre as the bodies responsible for overseeing the delivery of health services in the province of Nova Scotia and requires them to work collaboratively to do so.
Section 10 of the Health Services and Insurance Act and sections 9 through 13 of the Hospital Insurance Regulations define the terms for payments by the Minister of Health and Wellness to hospitals for insured hospital services.
In 2021-2022, there were 2,888 hospital beds in Nova Scotia (2.9 beds per 1,000 population). Department direct expenditures for insured hospital services operating costs were $2,220,898,704.
In Nova Scotia, the Health Services and Insurance Act acknowledges the federal contribution regarding the cost of insured hospital services and insured health services provided to provincial residents. The residents of Nova Scotia are aware of ongoing federal contributions to Nova Scotia health care through the Canada Health Transfer as well as other federal funds through press releases and media coverage.
The Government of Nova Scotia also recognized the federal contribution under the Canada Health Transfer in various published documents, including the following documents:
Reflects payments made to the public facilities noted for indicator 2.
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Scotia Surgery is not considered private; it is designated as a hospital under the Health Authorities Act (funded by the Department of Health and Wellness). The Nova Scotia Health Authority (NSHA) rents available capacity at Scotia Surgery. Procedures performed at Scotia Surgery are scheduled by NSHA staff and completed by surgeons in the public system. Scotia Surgery has no involvement in managing the physician or patient scheduling. Patients are scheduled based on the same criteria utilized for scheduling at other Central Zone sites.
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Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.
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Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
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Total services includes block funded dentists. This also includes maxillofacial and cleft palate surgeries.
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Total payments does not include block funded dentists.
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In New Brunswick, the formal name for Medicare is the Medical Services Plan. The Minister of Health (Minister) has the mandate and responsibility for operating and administering the plan by virtue of the Medical Services Payment Act and its Regulations. The Act and Regulations set out who is eligible for Medicare coverage, the rights of the patient, and the responsibilities of the Department of Health (the Department). This law establishes a Medicare plan, and defines which Medicare services are covered and which are excluded. It also stipulates the type of agreements the Department may enter into. As well, it specifies the rights of a medical practitioner; how the amounts to be paid for medical services will be determined; how assessment of accounts for medical services may be made; and confidentiality and privacy issues as they relate to the administration of the Act.
The Medicare and Physician Services 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.
The Regional Health Authorities Act establishes the Regional Health Authorities (RHA) and sets forth the powers, duties, and responsibilities of the same. The Minister is responsible for the administration of the Act, provides direction to each RHA, and may delegate additional powers, duties or functions to the RHA.
The Department of Health prepares and submits an Annual Report to the Legislature, and also provides information to the Office of the Comptroller for inclusion in their Public Accounts documents. The Minister and Department of Health executive team are accountable to answer questions of members of the Legislature pursuant to those Public Accounts documents. The most current Department of Health Annual Report can be found here.
Three groups have a mandate to audit the Medical Services Plan.
The Office of the Auditor General: In accordance with the Auditor General Act, the Office of the Auditor General conducts the external audit of the accounts of the province of New Brunswick, which includes the financial records of the Department. The Auditor General also conducts management reviews on programs as they see fit. Volume III Chapter 2 of the Auditor General's 2021 report referred to funding received and expended respecting the COVID-19 pandemic, and the effect on the provincial budget. The report's key findings can be found here.
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. Annual financial statements and supplementary information submitted to the Legislature by the Office of the Comptroller for all publicly funded purposes (including those associated with insured services under the Canada Health Act) can be found here.
Monitoring and Compliance Team: This team is tasked with managing compliance with the Medical Services Payment Act and Regulations, as well as the Negotiated Fee Schedule.
Legislation providing for insured hospital services as described in the Canada Health Act includes the Hospital Services Act, section 9 of Regulation 84–167, and the Hospital Act. Under Regulation 84–167 of the Hospital Services Act, New Brunswick residents are entitled to the following insured hospital services.
Insured in-patient services include:
Insured out-patient services include:
In 2021-2022 no amendments were made to the Acts or Regulations noted above, nor were any insured services added or deleted.
In 2021-2022 there was one private clinic in New Brunswick for diagnostic imaging. The Department has no relationship with this private entity, and does not foresee entering into one.
The Medical Services Payment Act and corresponding regulations provide for insured physician services. As of March 31, 2022, there were 1,820 participating physicians in New Brunswick.
A medical practitioner or an oral and maxillofacial surgeon who is practising in the province, outside the provisions of the Act and the Regulations (opted-out), shall inform any person to whom entitled services are provided that he or she is practising outside the provisions of the Act and the Regulations, and that the person is not entitled to payment under the Medical Services Plan. Further, practitioners can elect to opt-out for any given patient only for the total management of the patient's condition under care, including any complications which may develop within a reasonable length of time, and they must advise the patient in advance of rendering service that they are opting-out for those services.
An opted-in practitioner who subsequently wishes to change his status and opt-out totally can do so by notifying the Department of his intention in writing. His change in status becomes effective from the date of receipt by the Department of such written notification, or from the date specified by the practitioner. No physicians rendering health care services in this fiscal year so chose.
The services which residents are entitled to under Medicare include:
A physician or the Department of Health may request the addition of a new service. All requests are considered by the New Service Items Committee, which is jointly managed by the New Brunswick Medical Society and the Department. The decision to add a new service is based on conformity to the definition of "medically necessary" and whether the service is considered generally acceptable practice (not experimental) within New Brunswick and/or Canada. Considerations under the term "medically necessary" include services required for maintaining health, preventing disease and/or diagnosing or treating an injury, illness or disability. No public consultation process is used.
In 2021-2022 no amendments were made to the Act or Regulations.
Schedule 4 of Regulation 84–20 under the Medical Services Payment Act identifies the insured surgical- dental services that can be provided by a qualified dental practitioner in a hospital, providing the condition of the patient requires services to be rendered in a hospital.
In addition, a general dental practitioner may be paid to assist another dentist for medically required services under some conditions. In addition to Schedule 4 of Regulation 84–20, oral maxillofacial surgeons (OMS) have added access to approximately 300 service codes in the Physician Manual and can admit or discharge patients and perform physical examinations, including those performed in an out-patient setting. OMS may also see patients for consultation in their office.
As of March 31, 2022, there were 12 dentists and oral maxillofacial surgeons who provided services insured under the Medical Services Plan.
There is not a formally defined process through which new dental services may be added to the list of insured services; however, oral maxillofacial surgeons may approach government with such a request if they deem it appropriate. In 2021-2022 there were no such additions.
Uninsured hospital services include:
The services listed in Schedule 2 of New Brunswick Regulation 84–20 under the Medical Services Payment Act are specifically excluded from the range of entitled medical services under Medicare. They are as follows:
Dental services not specifically listed in Schedule 4 of the Dental Schedule are not covered by the Plan. Those listed in Schedule 2 are considered the only non-insured medical services.
There are no specific policies or guidelines, other than the Act and Regulations, to ensure that charges for uninsured medical goods and services (e.g., fibreglass casts), provided in conjunction with an insured health service, do not compromise reasonable access to insured services.
The decision to de-insure physician or surgical-dental services is based on the conformity of the service to the definition of "medically necessary," a review of medical service plans across the country, and the previous use of the particular service. Once a decision to de-insure is reached, the Medical Services Payment Act dictates that the government may not make any changes to the Regulation until the advice and recommendations of the New Brunswick Medical Society are received or until the period within which the Society was requested by the Minister to furnish advice and make recommendations has expired. Subsequent to receiving their input and resolution of any issues, a regulatory change is completed. Physicians are informed in writing following notification of approval. The public is usually informed through a media release. No public consultation process is used.
In 2021–2022, no services were removed from the insured services list.
Sections 3 and 4 of the Medical Services Payment Act and Regulation 84–20 define eligibility for the health care insurance plan in New Brunswick. Residents are required to complete a Medicare application and provide proof of identity, proof of residency, and proof of Canadian citizenship or a valid Canadian immigration document. A resident is defined as a person lawfully entitled to be, or to remain, in Canada, who makes their home and is ordinarily present in New Brunswick, but does not include a tourist, transient, or visitor to the province.
As of March 31, 2022, there were 805,375 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:
Residents who were not eligible for Medicare coverage during this reporting period included:
Persons who are discharged or released in New Brunswick from the Canadian Armed Forces, or a federal penitentiary, become eligible for coverage on the date of their discharge or release. An application must be completed and signed, and the applicant must provide proof of Canadian citizenship, proof of residency and the official date of release.
Non-Canadian new hires coming to Canada under a work permit must have a permit valid for a minimum of one year (or two six-month permits within a few months of each other). The Department of Health also requires a copy of their passport (including a copy of the last entry date stamp), and proof of residency in New Brunswick.
Children born out-of-country to Canadian citizens will take the eligibility status of the parent upon return to the province.
Should an individual disagree with a decision of the Department of Health, including a decision respecting eligibility to receive services, they may petition the Insured Services Appeal Committee, which shall provide advice to the Minister.
There were no amendments made to eligibility provisions in 2021-2022.
A person is eligible for New Brunswick Medicare coverage on the first day of the third month following the month permanent residency has been established. The three month waiting period is legislated under New Brunswick's Medical Services Payment Act. Refer to section 3.1 of this submission for exceptions; there were no amendments made to this section of the Act in 2021-2022.
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). This portion of the Act was not amended in 2021-2022.
Medicare coverage may be extended upon request in the case of temporary absences to:
Students: Those in full-time attendance at a university or other approved educational institution, who leave the province to further their education in another province, will be granted coverage for a 12 month period that is renewable, provided the following terms are met:
Residents: Residents temporarily employed in another province or territory are granted coverage for up to 12 months, provided the following terms are met:
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.
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 New Brunswick residents temporarily absent outside of Canada is determined in accordance with the Medical Services Payment Act.
Residents temporarily employed outside Canada are granted coverage for 182 days. This may be extended up to 12 months within a three year period upon approval from the Director of Medicare Eligibility and Claims. Exceptions to this are mobile and contract workers.
Coverage for any absence over 212 days for vacation purposes requires approval from the Director of Medicare Eligibility and Claims. This approval can only be for up to 12 months in duration and will only be granted once every three years.
New Brunswick residents exceeding the 12 month extension have to reapply for New Brunswick Medicare upon their return to the province. In this instance, cases are reviewed on a case by case basis. Depending on the circumstances, some cases may be eligible for first day coverage while others who have been away from the province slightly beyond the 12 month period may be given a grace period.
Insured residents who receive insured emergency services out-of-country are eligible to be reimbursed $100 per day for in-patient stays and $50 per out-patient visit. The insured resident is reimbursed for physician services associated with the emergency treatment at New Brunswick rates. The difference in rates is the patient's responsibility.
Mobile Workers: Mobile Workers are residents whose employment requires them to travel outside the province (e.g., pilots). The following guidelines must be met to receive Mobile Worker designation.
Mobile Worker status is assigned for a maximum of two years, after which the resident must reapply and submit documentation to confirm a continuation of Mobile Worker status.
Contract Workers: Any New Brunswick resident accepting a contract out-of-country must supply the following information and documentation:
Contract Worker status is assigned up to a maximum of two years. Any further requests for contract worker status must be forwarded to the Director of Medicare Eligibility and Claims for approval on an individual basis.
Students: Those in full-time attendance at a university or other approved educational institution in another country will be granted coverage for a 12 month period that is renewable, provided they comply with the following:
As part of the State of Emergency Mandatory Order a temporary change was made to subparagraph 3 (4)(a.1) of Regulation 84-20 under the Medical Services Payment Act effective April 23, 2021, extending expiry of coverage for residents who were temporarily absent, and had their coverage expire during the previous months, to May 31, 2021.
Medicare may cover out-of-country services that are not available in Canada on a pre-approval basis only. Residents may opt to seek non-emergency out-of-country services; however, they are responsible for assuming the total cost.
New Brunswick residents may be eligible for reimbursement if they receive elective medical services outside the country, provided the following requirements are met:
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.
A beneficiary who disagrees with a decision made by Medicare regarding their case or the case of an immediate family member can appeal to the Insured Services Appeal Committee. Beneficiary appeals can include decisions about eligibility, refusal of a claim payment for entitled services or the amount paid on a claim. The Committee includes members from the general public. It meets three to four times a year based on the number of cases. It reviews each case and presents recommendations to the Minister of Health who makes the final decision regarding an appeal.
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 Global Medical Management on the province's behalf.
Haemodialysis is exempt from the out-of-country coverage policy. Patients are required to obtain prior approval and Medicare will reimburse the resident at a rate equivalent to the current inter-provincial rate per session.
A New Brunswick patient may choose to receive most insured services paid by Medicare in any public hospital in Canada, without prior approval. Most of these services are covered by Interprovincial Reciprocal Billing Agreements, although some may be billed directly to the host province. Some procedures require prior Medicare approval before a patient will be accepted for treatment in another province (e.g. high cost procedures, residential addictions/mental health services, some plastic procedures etc.). Should such prior approval be required, the attending physician would write to the medical consultant with Medicare, providing pertinent documentation and the reason for the out-of-province referral. Travel is not covered by Medicare, but lodging may be considered if the patient meets Medicare's Hostel Policy criteria.
New Brunswick's health care system delivers equitable, quality care to the public it serves. As indicated in section 13.1 of Medical Services Payment Act Regulation 84–20, New Brunswick does not permit user fees for insured health services as defined by the Canada Health Act. New Brunswick uses a robust "comment based" approach to identifying individual citizens’ concerns on a wide range of health issues. In a typical month in the 2021–2022 fiscal year, the Department of Health received, logged, and responded to 150–200 concerns from individual New Brunswickers on issues including access to primary or specialized care, pharmaceutical approvals, access to services in a citizen's language of choice, wait times for specific services, the structure of specific programs, etc. The Department's web page provides several mechanisms to make such comments, including mailing addresses, e-mail addresses, telephone numbers, and a web-based message service.
In addition, in partnership with Regional Health Authorities, the Department of Health is exploring proactive mechanisms to ensure that no fees are levied upon citizens for primary care services offered by New Brunswick based providers.
Twelve requests for patient reimbursement for privately provided services were received in the 2020-2021 fiscal year, ranging from reimbursement for having blood drawn at a private collection site, to reimbursement for diagnostic imaging provided by a private provider (in each case, initiated by the individual). In accordance with New Brunswick's legislation described above, these requests were not eligible for reimbursement.
Access in a resident's official language of choice is not a limiting factor, regardless of where a resident receives services in the province.
Improving access to primary care and acute care is an ongoing focus within New Brunswick's health system. To support this focus while also responding to the significant challenge of the COVID-19 pandemic, the Government undertook significant new actions to address current and future needs:
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, alternate payment mechanisms or Family Medicine New Brunswick that may include a blended system.
The legislative authorities governing payments to hospital facilities in New Brunswick are the Hospital Act, which governs the administration of hospitals, and the Hospital Service Act, which governs the financing of hospitals. The Regional Health Authorities Act provides for the delivery and administration of health services in defined geographic areas within the province.
The Department mainly distributes available funding to New Brunswick's Regional Health Authorities (RHA) through a Current Service Level approach. The funding base of the RHA from the previous year is the starting point, to which approved salary increases and a global inflator for non-wage items are added. This applies to all clinical services provided by hospital facilities, as well as support services (e.g., administration, food services, etc.).
Funding for Service New Brunswick, a shared services agency that manages the information technology, materials management, laundry and clinical engineering components of the hospital facilities in New Brunswick, is also based on the Current Service Level approach.
Any requests for funding for new programs or services are submitted to the Deputy Minister of Health for approval. Funding for approved new programs or services is based on requirements identified through discussions between Department of Health and RHA staff. These amounts are added to the RHA funding base once there is agreement on the funding requirements.
New Brunswick recognizes the federal role regarding its contributions under the Canada Health Transfer in public documentation presented through legislative and administrative processes. Federal transfers are identified in the Main Estimates document and in the Public Accounts of New Brunswick. Both documents are published annually by the New Brunswick government.
There are no private for-profit facilities providing health insured services operating in New Brunswick.
Return to footnote 1 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.
Return to footnote 2 referrer
These are the number of physicians with an active physician status on March 31st of each year.
Return to footnote 3 referrer
Total payment for all payment methods.
Return to footnote 4 referrer
These are all physician services provided to residents and dispensed in another province. For NB, this is all services outside the province.
Return to footnote 5 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
Return to footnote 6 referrer
These are the number of dentists and oral maxillofacial surgeons (OMS) participating in New Brunswick's Medical Services Plan during a fiscal year. Routine dental services are not covered by New Brunswick Medicare therefore few dentists and OMSs are registered - only some emergency dental services done in hospital are covered by the Medical Services Plan.
Return to footnote 7 referrer
Quebec's hospital insurance plan, the Régime d’assurance hospitalisation du Québec, is administered by the Ministry of Health and Social Services (MSSS).
Quebec's health and drug insurance plans are administered by the Régie de l’assurance maladie du Québec (the Régie), a public body established by the provincial government that reports to the Minister of Health and Social Services.
Through the sound management of the Quebec Health Insurance Plan, the Public Prescription Drug Insurance Plan and assistance programs for the public, the Régie collaborates on access to health care. It also compensates health professionals so that Quebeckers can get the care they need.
The Public Administration Act (CQLR, c A-6.01, hereinafter "PAA") affirms the priority given by the government administration to the quality of services to the public in the development and application of the rules of the public administration. It recognizes the role played by parliamentarians with respect to government action and their contribution to improving services provided for the public while making the government more accountable to the National Assembly. As a result, the PAA establishes a framework for management based on results and transparency.
To ensure the implementation of this management framework, the PAA sets out a number of obligations that must be met by departments and agencies, including the production of a declaration of services to the public, if direct services to the public are offered, a multi-year strategic plan, an annual management report, and, in the case of departments, an annual expenditure management plan.
Section 24 of the PAA states that a department or body, including the MSSS and the Régie, must prepare an annual management report. This report must include a presentation of the results related to the objectives set out in the strategic plan, and a declaration by the Deputy Minister or agency head attesting to the reliability of the data in the report and the related controls, and any other element or information determined by Treasury Board or included in its laws.
In the case of the Régie, the annual management report includes a specific section on the results of the various control measures in place (inspections, investigations and amounts recovered) as well as the activity report on the basic prescription drug insurance plan.
In accordance with section 26 of the PAA, the annual management report of a department, and of the bodies and administrative units under a minister's responsibility, shall be tabled in the National Assembly by the minister concerned within four months after the end of their fiscal year or, if the Assembly is not sitting, within 15 days of resumption.
The Quebec Hospital Insurance Plan and the Quebec Health and Drug Insurance Plans are administered by the public authorities on a non-profit basis. All books and accounts are audited by the auditor general of Quebec.
The books and accounts of the Régie are audited by the Auditor General of Quebec each year and also whenever so ordered by the Government. These reports must accompany the Régie's annual management report.
Insured in-patient services outlined in the Regulation respecting the application of the Hospital Insurance Act (CQLR, c A-28) include the following:
Out-patient services covered by the Regulation respecting the application of the Hospital Insurance Act include the following:
The Ministry of Health and Social Services (MSSS) administers a free ambulance transportation program for persons aged 65 and older, in accordance with the parameters described in the Quebec policy on user transportation.
Services covered under this plan include medical and surgical services provided by physicians participating in the plan that are medically necessary, except those excluded by regulation.
The Régie de l’assurance maladie du Québec (the Régie) also covers the cost of the following:
The Régie also covers the following for "insured persons" within the meaning of the Health Insurance Act (CQLR, c A-29, hereinafter "HIA") who meet the eligibility criteria specific to each program:
This coverage applies only to aids and appliances covered in the Regulations. Financial aid is granted for external breast prostheses, ocular prostheses, devices provided to ostomies, and compression clothing for people with lymphedema. Coverage for eyeglasses and contact lenses applies exclusively to minors. Fixed financial assistance is provided for the purchase of professionally prescribed eyeglasses or contact lenses for vision correction. The following services may also be included in accordance with specific criteria and only in specific institutions:
Moreover, with respect to drug insurance, the Régie has covered, since January 1, 1997, in addition to recipients of last-resort financial assistance and persons aged 65 or over, insured persons who would not otherwise have access to a private drug insurance plan. In 2021–2022, 3.8 million people were covered by the Public Prescription Drug Insurance Plan.
The Régie also covers certain services offered in pharmacies that are reimbursed by the Health Insurance Act, such as vaccinations, COVID self-tests and certain consultations (minor conditions, no diagnosis).
Services insured under this plan include surgery performed by dental surgeons and specialists in oral and maxillofacial surgery, in a prescribed hospital centre or university institution.
Uninsured hospital services include:
Registration with the Hospital Insurance Plan is not required. Registration with the Régie de l’assurance maladie du Québec (the Régie) is sufficient to establish an individual's eligibility. Any individual residing or staying in Quebec as defined in the Health Insurance Act (CQLR, c A-29, hereinafter "HIA") must be registered with the Régie to be eligible for hospital services.
A person whose eligibility has been denied or who is dissatisfied with a decision of the Régie may request a review of the decision. The request for a review must be submitted to the Régie in a written notice setting out the reasons for the request. The request must be submitted within the six-month period following the date when the requester was informed of the decision.
As a last resort, within 60 days of being notified of the decision, a person may contest before the Tribunal administrative du Québec the decision for which the person has requested a review.
No relevant amendments to eligibility were made in 2021–2022.
Inmates in federal penitentiaries are not covered by the Quebec Health Insurance Plan.
Certain categories of residents, notably permanent residents under the Immigration Act and persons returning to live in Canada, become eligible under the plan following a waiting period of up to three months. Persons from another country receiving last-resort financial assistance benefits are eligible upon registration.
Canadian Forces personnel and their family members posted to Quebec from another Canadian province or territory who have status permitting them to settle there are eligible on the date of their arrival. Those who have not acquired Quebec resident status, and inmates of federal penitentiaries, become insured 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 et de l’Enseignement supérieur (Quebec Department of Education and Higher 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 may be eligible for the plan following a waiting period of up to three months.
On September 22, 2021, An Act respecting mainly the health insurance plan and prescription drug insurance plan eligibility of certain children whose parents’ migratory status is precarious came into effect. This law extends health and drug insurance coverage to children born to parents whose migratory status is precarious, who were not eligible until now and who are usually present in Quebec. These children will be eligible for coverage whether or not they were born in Quebec if their presence in the province for more than six months is demonstrated.
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 de l’assurance maladie du Québec (the Régie) and meet certain conditions.
If living outside Quebec in another province or territory for 183 days or more and provided they so notify the Régie, students and full-time unpaid trainees may retain their status as residents of Quebec:
This is also the case for persons living outside Quebec who are temporarily employed or working on contract there. Their resident status can be maintained for no more than two consecutive calendar years.
Persons who are directly employed or working on contract outside Quebec for a company or corporate body with its headquarters or a place of business in Quebec to which they report directly, or who are employed by the federal government or the Government of Quebec and are posted outside Quebec, or who are working on a contract as self-employed persons while their place of business is in Quebec, also retain their status as a resident of the province. The same is true of persons who remain outside the province for 183 days or more, but less than 12 months within a calendar year, provided such absence occurs only once every seven years.
Persons who work abroad as employees of a non-profit organization with its head office in Canada, as part of an international aid and co-operation program recognized by the Ministry of Health and Social Services (MSSS), or persons who stay abroad under a reciprocal agreement concluded by the MSSS, maintain their eligibility.
Insured persons who leave Quebec to settle in another province or territory of Canada remain eligible for health insurance for up to three months after their departure, but their eligibility for the Quebec Drug Plan ends on the day of their departure.
However, coverage for insured persons who leave Quebec to permanently move abroad terminates the day of their departure.
The costs of insured services provided by health professionals to an insured person in another province or territory of Canada are reimbursed for the amount actually paid or at the rate that would have been paid by the Régie for such services in Quebec, whichever is lower. Exceptionally, for the Outaouais region, Quebec has negotiated a permanent arrangement with Ontario to pay Ottawa medical specialists 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 Centre intégré de services de santé et de services sociaux de l’Outaouais [Outaouais integrated health and social services centre] pays the difference between the cost invoiced by Ontario and the amount initially reimbursed by the Régie. A similar agreement was signed in December 1991 between the Centre de santé Témiscaming [Témiscaming Health Centre] and the North Bay Regional Health Centre.
The service provided must be an insured service within the meaning of the Act. Services that are experimental in nature are not reimbursed.
Costs for hospital services provided to an insured person in another province or territory of Canada are paid in accordance with the terms and conditions of the Hospital Reciprocal Billing Agreement regarding hospital insurance agreed to by the provinces and territories of Canada. These costs are paid either at the established per diem for hospitalization in a standard ward or in intensive care proposed by the host province and approved by all the provinces and territories or, in cases of out-patient services or expensive procedures, at the approved interprovincial rates. Services that are excluded from interprovincial agreements but covered under the provincial program are reimbursed at the rate in force.
During a temporary stay outside Canada, the Régie reimburses the full cost of emergency hospital services and 75 per cent of the cost in other cases to students enrolled in an educational institution outside Canada; full-time unpaid interns in a university, an institution affiliated with a university, a research institute or a government or international organization; Quebec public servants posted abroad; and employees of a non-profit organization with a head office in Canada that works as part of an international aid or co-operation program recognized by the MSSS. However, when such persons go on holiday outside their place of study, training or work, this coverage is no longer in force, and regular coverage for hospital services applies.
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 MSSS and the country in question.
For residents who are not in one of the above situations and receive insured services in a hospital outside Canada, the Régie reimburses the cost of such services, when they become necessary due to an emergency or sudden illness, to a maximum of $100 CAD per day if the patient was hospitalized, including for day surgery, or to a maximum of $50 CAD per day for outpatient services. However, hemodialysis treatments are covered to a maximum of $220 CAD per treatment. The services must be delivered in a hospital, or hospital centre, recognized and accredited by the appropriate authorities. No reimbursements are made for nursing homes, spas or similar establishments.
To receive full reimbursement for professional and hospital services elsewhere in Canada or in another country, which are insured but not available in Quebec, a written request signed by two physicians with expertise in the field of the pathology of the person on whose behalf the request is made must first be sent to the Régie. The request must be accompanied by a summary of the insured person's medical file, describe the specialized services required by the insured person, attest to the unavailability of said services in Quebec or Canada, and contain information about the treating physician and the name and address of the hospital where the services are to be provided. Following an evaluation of the request by the Régie, authorization to receive the services is either given or denied. No authorization will be given if the service is available in Quebec or if it is an experimental service.
A person whose request has been denied or who is dissatisfied with a decision of the Régie may request a review of the decision. The request for a review must be submitted to the RAMQ in a written notice setting out the reasons for the request. The request must be submitted within the six-month period following the date when the requester was informed of the decision.
Within 60 days of being notified of the decision, a person may contest before the Tribunal administrative du Québec the decision for which the person has requested a review.
Everyone has the right to receive adequate health care services without any kind of discrimination. In Quebec, the Health Insurance Act (CQLR, c A-29, hereinafter "HIA") does not allow user fees to be imposed. It also prohibits any person from demanding or receiving any payment from an insured person for incidental fees related to an insured service, except in cases prescribed by regulation or provided for in an agreement and the conditions mentioned therein. If an insured person thinks that they have been incorrectly billed fees, they may request reimbursement from the Régie de l’assurance maladie du Québec (the Régie), which will determine whether any amounts have been unjustifiably billed. If appropriate, the Régie will reimburse the insured person and will recover the amount reimbursed from the health-care professional or the clinic involved. It is also possible to reimburse insured persons who have not made reimbursement requests if the Régie finds that fees have been charged to them illegally.
A situation that appears to be illegal with respect to fees charged to an insured person may also be reported to the Régie which, after verification, will follow up appropriately. These follow-ups may include an inspection or an investigation of the clinics or the professionals involved. Residents who have reason to believe they have been subject to patient charges can contact the Régie.
In more detail, as of March 31, 2022, the health and social services network had 139 institutions: 51 public and 88 private. These institutions administer 1,573 facilities or physical spaces providing health and social services to the Quebec population.
The 51 public institutions are administered by 34 president-CEOs or CEOs. They include integrated centres whose legal name is Centre intégré de santé et de services sociaux (CISSS) [health and social services centre] and Centre intégré universitaire de santé et de services sociaux (CIUSSS) [integrated university health and social services centre], as well as grouped institutions and other institutions that have been neither grouped nor merged.
As of April 1, 2015, each of the 22 integrated centres is the result of the merger of all or some of the public institutions in a given health and social services region, as the case may be, with the health and social services agency. Nine of the 22 integrated centres can call themselves a "centre intégré universitaire de santé et de services sociaux" (CIUSSS) because they are located in a health and social services region in which a university offers a complete predoctoral program of study in medicine, or because they operate a centre designated as a university institute in the field of social services.
For their part, the 29 remaining public institutions are distributed as follows:
Quebec also has four integrated university health and social services networks (réseaux universitaires intégrés de santé et de services sociaux or RUISSS) which promote co-operation, complementarity and integration of the care, teaching and research missions of the health facilities and universities with which they are affiliated. In addition to the services provided by public facilities, the population also has access to the services of private facilities which offer accommodation, long-term care and other services.
Since 2002, Family Medicine Groups (GMFs) have served as flagships for the organization of front-line health care and services in Quebec. GMFs promote teamwork, collaboration among professions, institutional responsibility to the population, and the development of trust and close collaboration between patients and clinicians. The GMF program provides financial and professional support tailored to the realities of clinicians and the needs of patients, and ensures equitable, patient-centred funding, professional support (nursing personnel, social workers, pharmacists and other health professionals), a more balanced service offer, less burdensome administrative procedures, and mandatory use of electronic health records. These features have the voluntary support of physicians and the benefit of a team funding structure.
The elementary structure of the GMFs ensures that registered patients have reasonable and timely access, as is demonstrated by the use of a measurement of patient attendance at the GMF where they are registered. Also, measures were recently added to the program to engage GMFs in a territorial service offer for patients waiting for a family physician.
As of March 31, 2022, Quebec had nearly 370 recognized GMFs in its territory. On the same date, there were about 50 GMF networks.
Physicians are remunerated in accordance with the negotiated fee schedule. The Minister may enter into an agreement with the organizations representing any class of health professional.
The HIA governs the compensation of health professionals (physicians, dentists, optometrists and pharmacists). While the majority of physicians practise within the provincial plan, Quebec allows two other options:
To become a non-participant, a health professional must notify the Régie by registered or certified mail. The non-participation takes effect the thirtieth (30th) day from the date of mailing, and re-enrollment takes effect the eighth (8th) day following the date of mailing of the notice (Regulation respecting the application of the Health Insurance Act, s. 29).
There are various modes of remuneration:
Awareness-Raising Mechanisms
The Régie issues notifications to the MSSS with respect to issues and risks associated with controlling the payment of health-care professionals on the basis of the agreements negotiated. Thus, based on its analyses, the Régie's findings may result in the issuance of notifications on different issues even if they apply more to medical practice or the organization of services.
Systematic Controls
These measures are aimed at the overall billing of health-care professionals or agreement situations. The controls are carried out manually, by computer, by taking samples, or by monitoring. Systematic controls may be followed by specific controls if the Régie deems it necessary to do an in-depth analysis of a situation with a professional or a limited group of professionals (see next section).
Specific Controls (inspections, investigations, service audits performed)
These measures are aimed at the billings of a professional or a limited group of professionals for whom practices have been identified as at risk of being non-compliant or potentially abusive or fraudulent. A specific audit may also be initiated following a complaint or a tip.
The Régie recovers the amounts that have been inappropriately paid by means of a compensation or recovery mechanism.
The Régie has a monitoring mechanism to ensure that professionals with non-compliant, abusive or fraudulent billings are subject to monitoring.
The MSSS funds hospitals through payments directly related to the cost of insured services provided.
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 (MOH), Ontario's health care system was supported by over $67.8 billion in spending during 2021-2022.
In response to the COVID-19 outbreak, Ontario implemented the following temporary funding changes related to its health insurance program:
The COVID-19 outbreak also resulted in a constrained global supply chain, which impeded health service provider (HSP) access to Personal Protective Equipment (PPE) and other critical supplies. In response to these challenges:
Ontario Health Care and Health Care Planning
The Ontario Health Insurance Plan (OHIP) is administered on a non-profit basis by the Ministry of Health (MOH). OHIP was established in 1972 and is continued under the Health Insurance Act (HIA), Revised Statutes of Ontario, 1990, c. H-6, to provide insurance in respect of the cost of insured services provided to Ontario residents (as defined in the HIA) in hospitals and health facilities, and by physicians and other health care practitioners.
The MOH provides services to the public through programs such as health insurance, drug benefits, assistive devices, forensic mental health and supportive housing, home care, community and public health, and health promotion and disease prevention. It also regulates hospitals and nursing homes, medical laboratories and specimen collection centres, and coordinates emergency health services.
Local Health Integration Networks (LHIN) are governed by the Local Health System Integration Act, 2006 (LHSIA). From April 1, 2007 to March 31, 2021, Ontario's fourteen (14) LHINs served as Ontario's regional health authorities and had responsibility for funding, planning, and integrating health care services at the local level. This included services delivered by hospitals, long term care homes, community care access centres, community health centres, community support service agencies, and mental health and addictions agencies.
In 2017, the community care access centres were transferred into the LHINs’ and the LHINs role was expanded to include the provision of home and community care services and long-term care home placement services.
On February 26, 2019, Ontario announced its long-term plan to transform the health system to one that provides better patient and provider experiences, better population and health outcomes, and improves value, efficiency, and long-term sustainability. Ontario is creating an integrated public health care system by coordinating the work of existing provincial health agencies, organizations, and programs. On February 26, 2019, the Minister of Health and Long-Term Care introduced Bill 74, the People's Health Care Act, 2019 that enabled the phased transfer of many government agencies into a single agency, Ontario Health (OH). OH, a Crown agency, has the mandate to ensure the quality and sustainability of the provincial health system by, among other functions, overseeing health care delivery, improving clinical guidance, and providing support for providers to ensure better quality care for patients.
On December 2, 2019, the following five health agencies were transferred into OH in accordance with the Connecting Care Act 2019:
By Minister's order under the Connecting Care Act, 2019, the health system planning, funding and community engagement functions of the LHINs transferred into Ontario Health. LHINs then began operating under a new business name, Home and Community Care Support Services, and retained their mandate to deliver home and care services, place people in long-term care homes, supportive housing programs, chronic care and rehabilitation beds in hospitals and other programs where home and community care services are provided and make community referrals.
On April 1, 2021, the Trillium Gift of Life Network (TGLN) and the health system planning and funding (i.e., non-patient care) functions of the LHINs transferred to OH. After its transfer into OH, TGLN was dissolved.
As the COVID-19 response begins to stabilize and plans are underway to reopen the economy, the Ministry has resumed planning for the next phase of OH transfers and transformation work without negatively impacting COVID-19 efforts or compromising patient care.
The transformation will take place over a number of years. It will continue to roll out in carefully planned phases to ensure patient care is not interrupted.
Section 2 of the HIA stipulates that the Minister of Health is responsible for the administration and operation of OHIP and is Ontario's public authority for the purposes of the Canada Health Act.
Annually, the MOH reports on its plans, results and outcomes via a published plan and annual report. The MOH's published plan and annual report are tabled in the legislature and published on the MOH's website.
Every year the Auditor General of Ontario reports on the results of their 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 MOH chosen for review by the Auditor General are included within this annual report, the last of which was released on December 17, 20210.
The MOH's accounts are published annually in the Public Accounts of Ontario. The 2021-2022 Public Accounts of Ontario were tabled and released on September 23, 2022.
The Auditor General of Ontario's 2021 Annual Report was released on December 1, 2021. The following sections made specific reference to the operation of OHIPFootnote iii:
The Auditor General of Ontario also released Special Reports on May 12, 2021 and April 28, 2021, which make specific reference to the operation of OHIP:
Insured in-patient and out-patient hospital services in Ontario are prescribed in sections 7 and 8 of Regulation 552 under the Health Insurance Act (HIA).
In keeping with the provisions of the Canada Health Act, the Ontario Health Insurance Plan (OHIP) insures all medically necessary hospital services. Hospital services are all services that are medically required to be performed in hospital. These are described in the Regulations as follows.
Insured in-patient hospital services include medically required:
Insured out-patient services include medically required:
Each individual hospital service is not specifically listed in Regulation 552; rather, the Regulation lists the above broad categories of services so that new medical and technological advances are automatically included as they become accepted standards of practice.
Regulatory changes are approved by Cabinet and generally there is a public consultation process by way of Ontario's Regulatory Registry.
No regulation changes to insured hospital services were completed in fiscal year 2020-2021.
Insured physician services are prescribed in Regulation 552 under the HIA. Under Regulation 552 of the HIA, a service provided by a physician in Ontario is an insured service if it:
Physicians provide insured medical, surgical, and diagnostic services, including primary health care services. Services are provided in a variety of settings, including physician offices, community health centres, hospitals, mental health facilities, licensed Independent Health Facilities, and long-term care homes. Physicians also provide certain insured services virtually, where appropriate.
In general terms, insured physician services include:
Physicians must be registered to practice medicine in Ontario by the College of Physicians and Surgeons of Ontario, and, both the patient and physician must be located in Ontario when rendering the service in order for the services to be covered under OHIP.
During 2021–2022, most physicians submitted claims for all insured services rendered to insured persons directly to OHIP, and a small number of physicians billed the insured person. Physicians who do not bill OHIP directly are commonly referred to as having opted-out of the Plan. When a physician has opted-out of the Plan the physician bills the patient an amount not exceeding the amount payable for the service under the Schedule of Benefits—Physician Services (this was permitted on a ’legacy’ basis following proclamation of the Commitment to the Future of Medicare Act [CFMA] in 2004). The patient then recoups that amount from the Plan.
There were approximately 34,798 physicians who submitted claims to OHIP in 2021–2022. This figure includes physicians submitting both fee-for-service claims and physicians included in an alternative payment plan who submitted tracking or shadow-billed claims. In 2021–2022, there were 14 opted-out physicians in Ontario.
The Schedule of Benefits — Physician Services is regularly reviewed and revised to reflect current medical practice and new technologies. In 2021-2022, temporary physician funding initiatives previously introduced to address the provision of physician services during the COVID-19 pandemic, were extended including through regulatory amendments. This process involved consultation with the Ontario Medical Association (OMA) and negotiation of payments with the OMA under the Binding Arbitration Framework between the Ministry and the OMA.
In accordance with the Canada Health Act, certain surgical-dental services are prescribed as insured services under Regulation 552 in the HIA and listed in the Schedule of Benefits— Dental Services. The Act authorizes OHIP to pay for a limited number of procedures when the procedure is performed in a public hospital graded under the Public Hospitals Act as Group A, B, C, or D, by a dental surgeon who has been appointed to the dental staff of the public hospital.
Generally, insured dental services include:
With respect to insured surgical-dental services, the MOH consults with the Ontario Dental Association in making changes to the Schedule of Benefits - Dental Services.
The required regulatory changes are approved by Cabinet and generally there is a public consultation process by way of Ontario's Regulatory Registry.
In Ontario, in the fiscal year 2021-2022, 894 dentists had active billing numbers and 253 dentists billed OHIP. There were 638 dentists who had active billing numbers but did not bill OHIP. Following proclamation of the CFMA in 2004, dentists are required to submit claims for all insured surgical-dental services to OHIP, i.e., are prohibited from charging the patient for insured services. No dentists are ‘opted-out’ under ’legacy’ provisions.
Uninsured hospital services include but are not limited to:
Section 24 of Regulation 552 details some specified physician and dental surgical services that are not insured services.
Uninsured physician services may include:
Under section 24, treatment for a medical condition that is generally accepted within Ontario as experimental is also not insured.
Additionally, "add ons" to insured services that are considered non-medically necessary and optional upgrades to a basic insured service (e.g., upgraded cataract lenses, specialized testing for cataract surgery, fibreglass casts, etc.) are uninsured services for which a patient may be charged.
Dental services provided in dentists’ private offices are not insured and payment is the responsibility of the individual patient. Dental services not specifically listed in the Dental Schedule are also not insured, including such services as prosthetic restorations (fixed bridges and dentures) for the replacement of teeth, orthodontic treatment, fillings, and crowns.
In an effort to uphold requirements under the Canada Health Act to prohibit extra-billing and user charges (EBUC) for insured health care services, Ontario's Commitment to the Future of Medicare Act provides authority to obtain information and take certain actions related to allegations of EBUC. Specifically, with respect to EBUC the CFMA makes it illegal:
For more fulsome information on the CFMA, please refer to section 5.1.
Under the Independent Health Facilities Act (IHFA), the MOH provides facility fee funding for overhead costs that support, assist or are a necessary adjunct to the provision of insured services rendered in non-hospital facilities when these costs are not included as part of the insured service. Under this Act, facility fees are payable only by the Minister of Health or Ontario Health and only to a licensed Independent Health Facility, and charges to or receipt of a facility fee payment from a patient in any other manner is an illegal facility fee.
The MOH reviews all possible violations of the CFMA and IHFA that come to its attention. Possible violations come to the MOH's attention from various sources such as patient complaints, the media, advertisements, health care providers and their staff and Members of Provincial Parliament. In some cases, the MOH may also review possible violations of the CFMA and IHFA on a proactive basis (i.e., without receiving a complaint tied to a specific patient). If it is found that a patient has paid an unauthorized payment, the MOH ensures that patients are reimbursed in accordance with provisions of the CFMA.
Providers and facilities are legally permitted to charge patients for uninsured services, either on a fee-for-service basis, or through a block or annual fee, which covers a group of uninsured services rendered by a physician, practitioner, or hospital over a specified time period.
The MOH does not regulate charges for uninsured services, or for services rendered to uninsured persons nor does the MOH set prices for uninsured services.
The College of Physicians and Surgeons of Ontario (CPSO), the body governing the practice of medicine in Ontario, is responsible for ensuring that charges by physicians for uninsured services, including block fees are in accordance with professional standards of practice. The MOH's interest in block fees is to ensure that they do not create a barrier to accessing insured services, do not include charges for insured services, do not confer preferential access to insured services, or constitute illegal facility fees contrary to Ontario law. However, the Ministry does not regulate the amount charged for block fees or the types of uninsured services that may or may not be included in block fees.
The CPSO has established guidelines with respect to charging patients for uninsured services and is responsible for investigating professional practice complaints against physicians, such as for excessive fees. The MOH directs patients who have complaints regarding charges for uninsured services to the CPSO.
A regulatory amendment is required for changes to OHIP insured physician services, including potential public consultation via the Regulatory Registry.
Section 11 of the Health Insurance Act (HIA) specifies that every person who is a resident of Ontario is entitled to become an insured person under the Ontario Health Insurance Plan (OHIP) upon application. In order to be considered an Ontario resident, Regulation 552 under the HIA, with a few exceptions that are noted in the Regulation, requires that a person must:
Individuals who are not eligible for OHIP coverage are those who do not meet the definition of a resident, such as tourists, visitors to the province, and those who do not hold an immigration or other similar status as defined in the Regulation. Services that a person is entitled to receive under federal legislation are not insured services, for example, those provided to federal penitentiary inmates and Canadian Forces members. Services that a person is entitled to receive under the Workplace Safety and Insurance Act are also not insured services in Ontario.
When it is determined that a person is not eligible, or is no longer eligible, for OHIP coverage, a request may be made by the person to the Ministry of Health (MOH) to review the decision. Anyone may request that the MOH review the denial of their OHIP eligibility by making a request in writing to the OHIP Eligibility Review Committee (OERC). Those who are not satisfied with the OERC's decision regarding their OHIP eligibility may request an appeal of their case by the Health Services Appeal and Review Board.
The MOH is the sole payor for medically necessary OHIP insured physician, hospital, and hospital surgical-dental services. An eligible Ontario resident may not obtain any benefits from another insurance plan for the cost of any insured service that is covered by OHIP. As noted, the waiting period has been removed in response to the pandemic.
Persons who were previously ineligible for OHIP coverage but whose status and/or residency situation has changed may be eligible upon application, subject to the requirements of Regulation 552. There were 14,646,581 valid and active health card users in Ontario as of March 31, 2022.
The MOH provides health insurance coverage to a limited number of specified categories of individuals in of Ontario, other than Canadian citizens and permanent residents or landed immigrants.
These individuals are required to provide acceptable original documentation to support that they meet the definition of resident for the purposes of OHIP coverage in the same manner as Canadian citizens and permanent resident or landed immigrant applicants.
The individuals listed below may be eligible for OHIP coverage in accordance with Regulation 552 of the HIA. Individuals are required to apply in person to ServiceOntario, which has the government-wide mandate for the delivery of front-facing services to the residents of Ontario, including the issuance of the Ontario Photo Health Card.
As of March 19, 2020, the province has removed the three-month waiting period requirement for OHIP coverage.
Applicants for Permanent Residence: These are persons who have submitted an application for Permanent Resident status to Immigration, Refugees and Citizenship Canada (IRCC), and IRCC 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/Convention Refugees: These are persons who are determined to be Protected Persons/Convention Refugees under the terms of the federal Immigration and Refugee Protection Act. Members of this group are provided with immediate OHIP coverage.
Holders of Temporary Resident Permits: A Temporary Resident Permit is issued to an individual by IRCC when there are compelling reasons to admit an individual into Canada who would otherwise be inadmissible under the federal Immigration and Refugee Protection Act. Each Temporary Resident Permit has a case type or numerical designation on the permit that indicates the circumstances allowing the individual entry into Canada. Individuals who hold a permit with a case type of 86, 87, 88, 89, 90, 91, 92, 93, 94, 95 or 80 (if for adoption) are eligible for OHIP coverage.
Foreign Clergy, Foreign Workers and their Accompanying Family Members: An eligible foreign clergy is a person who is sponsored by a religious organization or denomination if the member has finalized an agreement to minister to a religious congregation or group in Ontario for at least six months, as long as the member is legally entitled to stay in Canada.
A foreign worker is eligible for OHIP if the individual has been issued a Work Permit or other document by IRCC that permits the person to work in Canada, and if the person also has a formal agreement in place to work full-time for an employer in Ontario. The work permit or other document issued by IRCC, 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 clergy or an eligible foreign worker is also eligible for OHIP coverage as long as the spouse or dependant is legally entitled to stay in Canada.
Applicants for Canadian Citizenship: These individuals are eligible for OHIP coverage if they have submitted an application for Canadian citizenship under section 5.1 of the federal Citizenship Act, even if the application has not yet been approved, provided that IRCC has confirmed that the person meets the eligibility requirements to apply for citizenship under that section and the application has not yet been denied.
Children Born Out-of-Country: A child born to an OHIP-eligible woman who was transferred from Ontario to receive insured health services that were pre-approved for payment by OHIP is eligible for immediate OHIP coverage provided that the mother was pregnant at the time of departure from Ontario.
Seasonal Agricultural Farm Workers: Are persons who have a Work Permit issued under the Seasonal Agricultural Worker Program administered by the Government of Canada. Due to the special nature of their employment, migrant farm workers do not have to meet any other residency requirement and are provided with immediate OHIP coverage.
Holders of Emergency Authorizations: Are persons in Ontario who have been granted an emergency authorization to enter into and remain in Canada for humanitarian reasons for the duration of that authorization or any subsequent authorizations. This applies to individuals arriving under Canada-Ukraine Authorization for Emergency Travel (CUAET).
No premiums are required to obtain OHIP coverage. There is an Ontario Health Premium that is collected through the provincial income tax system, but it is not connected to OHIP registration or eligibility in any way. Responsibility for the administration of the Ontario Health Premium lies with the Ontario Ministry of Finance.
Prior to March 19, 2020, in accordance with section 5 of Regulation 552 under the Health Insurance Act (HIA), individuals who moved to Ontario were typically entitled to Ontario Health Insurance Plan (OHIP) coverage three months after establishing residency in the province unless listed as an exception in Regulation 552, or subsection 11(2.1) of the HIA.
Assessment of whether or not an individual was subject to the waiting period occurred at the time of their application for OHIP coverage. Examples of those who were exempt from the three-month waiting period included newborn babies, eligible military family members, and insured residents from another province or territory who moved to Ontario and immediately became residents of an approved long-term care home in Ontario.
In accordance with Regulation 552 under the HIA and as provided for in the Interprovincial Agreement on Eligibility and Portability, persons who permanently moved to Ontario from another Canadian province or territory where they are insured were typically eligible for OHIP coverage after the last day of the second full month following the date residency is established, in other words, an interprovincial waiting period.
Effective March 19, 2020, in response to the COVID-19 pandemic, Regulation 552 under the HIA was amended to remove the waiting period for OHIP for all new and returning residents of Ontario. Currently no waiting period for OHIP coverage exists.
Ontario adheres to the terms of the Interprovincial Agreement on Eligibility and Portability (EPA), as per section 1.6 of Regulation 552, and in accordance with the EPA, an insured person who leaves Ontario temporarily to travel within Canada, without establishing residency in another province or territory, may continue to be covered by OHIP for a period of up to 12 months.
An insured person who temporarily seeks or accepts employment in another province or territory may continue to be covered by OHIP for a period of up to 12 months. If the individual plans to remain outside Ontario beyond the 12-month maximum, he or she should apply for coverage in the province or territory where that person has been working or seeking work.
As per section 1.8 of Regulation 552, and in accordance with the EPA, insured students who are temporarily absent from Ontario, but remain within Canada, may be eligible for continuous OHIP coverage for the duration of their full-time studies, provided they do not establish permanent residency elsewhere during this period. To ensure that they maintain continuous OHIP eligibility, a student should provide the Ministry of Health (MOH) with documentation or information 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.
Also, in accordance with section 1.6 and 1.8 of Regulation 552 of the HIA, 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.
Payments for insured out-of-province services are prescribed under sections 28, 28.0.1, 28.0.2, and 29 of Regulation 552 of the HIA. Insured residents who are temporarily outside of Ontario can use their valid Ontario health card to obtain insured physician (except in Quebec) and hospital services generally at no direct cost.
Ontario participates in Reciprocal Hospital Billing Agreements with all other provinces and territories for payment of insured in-patient and out-patient hospital services. For the 2020-2021 year, rates were set and approved by the Interprovincial Health Insurance Agreements Coordinating Committee. Payment for in-patient services depends on the hospital's approved in-patient per diem rate. Payment for out-patient services is at the standard approved out-patient rate.
Ontario is also party to the Reciprocal Medical Billing Agreements with all other provinces and territories, except Quebec (which does not participate in reciprocal medical billing). Ontario residents who have been directly billed for insured physician or hospital services in another province or territory can submit their receipts to MOH for reimbursement. Reimbursement of insured physician services is at the rates payable in the Ontario Schedule of Benefits for Physician Services or the amount billed, whichever is less. Reimbursement of insured hospital services is at the established rates or the amount billed, whichever is less.
Physicians and hospitals are not parties to the Reciprocal Hospital Billing and Reciprocal Medical Billing Agreements and such providers in other provinces and territories may bill Ontario residents directly for services rendered. Ontario residents billed directly may submit claims for reimbursement to OHIP.
Out-of-Province (Within Canada)
Out-of-province (but within Canada) authorized laboratory tests performed outside of a publicly funded hospital require prior approval of funding in accordance with Section 28.0.2 of Regulation 552. In addition, certain medical services that require prior approval of funding in Ontario (as prescribed in the Schedule of Benefits for Physician Services such as breast reduction and panniculectomy) must be prior approved if the service is sought in another province or territory.
Residents may be temporarily outside of Canada for a total of 212 days in any 12-month period and still maintain OHIP coverage as long as their primary place of residence remains Ontario.
Extended Absences:
Health insurance coverage for insured Ontario residents during extended absences (longer than 212 days) outside Canada is governed by Regulation 552 of the HIA.
The MOH requests that residents apply to MOH to confirm this coverage before their departure and provide documents explaining the reason for their absence.
In accordance with Regulations and MOH policy, most applicants must also have been residents in Ontario for at least 153 days in each of the two consecutive 12-month periods before their expected date of departure.
The length of time that a person can receive continuous Ontario health insurance coverage during an extended absence outside Canada varies depending on the reason for the absence as follows:
Spouses and dependants may also qualify for continuous OHIP coverage while accompanying the primary applicant on an extended absence outside Canada.
Regulation 552 under the HIA sets out eligibility criteria and payment authority for funding emergency health care costs incurred by eligible Ontarians who are temporarily absent from Canada, such as for travel, work, and studying.
The provisions under this program provide reimbursement at very limited rates for medical treatment required to treat illnesses, diseases, conditions, or injuries that are acute, unexpected, arose outside of Canada and required immediate treatment.
OHIP reimburses patients at the following rates:
These provisions are intended and designed to provide a very limited amount of funding for the medical treatment of insured residents of Ontario if they incur costs related to an unexpected illness, disease, condition or injury that arose while they are outside of Canada and that requires immediate treatment. This program does fund treatment if the illness, disease, condition, or injury arises before the patient leaves Canada, or if it is not acute or unexpected.
As set out in Regulation 552 under the HIA, payment for non-emergency health services provided outside of Canada requires written prior approval from the General Manager of OHIP before the services are rendered.
With written prior approval, full funding for out-of-country medical services is paid directly to out-of-country hospitals, health facilities, and physicians as well as laboratories for medically necessary insured services that are not performed in Ontario or, with the exception of laboratory services, for services that cannot be obtained in Ontario without medically significant delay.
In accordance with the requirements of Regulation 552 under the HIA, the requested out-of-country medical services are eligible for funding as insured services only if they are:
Requests for prior approval of funding must be submitted by an Ontario physician and generally require written confirmation from a specialist, as defined in the Schedule of Benefits, in the type of services for which prior approval has been requested, to confirm that the regulatory criteria for the funding of out-of-country medical services are met. This requirement does not apply to emergency services or services that are within a general practitioner's scope of practice.
There are also other specified requirements in section 28.4 of Regulation 552 depending on the nature of the service for which funding is requested.
Funding requirements for laboratory tests performed outside Canada are described in section 28.5 of Regulation 552 of the HIA.
In the case of a denial of funding, the referring Ontario physician and the patient are advised that the decision may be reviewed by the Ministry if additional medical information is submitted for consideration. Internal reviews may be requested as often as needed, provided new additional supporting medical documentation is submitted. In addition, the patient may appeal an out-of-country funding decision to the Health Services Appeal and Review Board.
Funding for all insured hospital, physician, health facility and practitioner services provided to insured Ontario residents is in accordance with the Health Insurance Act (HIA) and regulations. Access to insured services without charges is protected under Part II of the Commitment to the Future of Medicare Act (CFMA), "Health Services Accessibility." The CFMA prohibits extra-billing by including a provision that prohibits any physician or designated practitioner from charging or accepting payment or other benefit for rendering an insured service to an insured person for more than the amount that is paid by Ontario Health Insurance Plan (OHIP). The CFMA also prohibits a physician or designated practitioner from accepting payment or benefit for an insured service rendered to an insured person except from OHIP (subject to a few specified exceptions) and prohibits any person or entity from charging or accepting payment or other benefit for an insured service rendered to an insured person except as outlined above or as specified in the regulations.
The CFMA further prohibits queue-jumping through a provision that prohibits any person or entity from paying, charging, or accepting payment or other benefit in exchange for conferring upon an insured person a preference in obtaining access to an insured service. 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" or "annual" fee for uninsured services.
The CFMA contains provincial offence provisions, where individuals and corporations in violation of the Act may be subject to fines set out in the Act.
The Ministry of Health (MOH) reviews all possible contraventions of the CFMA that come to its attention. For situations in which it is determined that an unauthorized payment has occurred, the MOH takes steps to ensure that the amount is repaid to the payee.
For complaints regarding charges for insured services, the CFMA program of the ministry can be reached at 1-888-662-6613 or by email at: [email protected].
Health Card Validation (HCV) assists health care providers with access to information requested for claims payment. HCV allows the provider to determine the point-in-time validity of a patient's Ontario health number (and version code) indicating eligibility or ineligibility for provincially funded health care services, thereby reducing claim rejects. A health care provider may subscribe for validation services if they have a valid and active billing number as assigned by the MOH. If patients require access to insured services and do not have a valid health card in their possession, upon obtaining patient consent, the provider may obtain the necessary information by utilizing the accelerated health number release service provided by ServiceOntario's Health Number Look Up service, which is offered 24 hours a day, 365 days per year to physicians or hospitals registered for this service.
Acute care priority services are designated, highly specialized, hospital-based services that deal with life-threatening conditions such as organ transplants, cancer surgery and treatments, and neuro services. These services are often high-cost and are rapidly growing, which has made access a concern. Generally, these services are managed provincially, on an ongoing basis by continually monitoring demand and adjusting funding as needed.
Acute care priority services include:
Primary Health Care: 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 underserviced communities.
Interprofessional Care Models:
Family Health Teams (FHT) are independent, non-profit organizations that provide interdisciplinary team-based primary health care; they are staffed by providers such as nurse practitioners, nurses, social workers, and dieticians. Physician groups that can affiliate with and participate in FHTs are funded by one of three compensation options: Blended Capitation (such as FHN or FHO), Complement Based Models (RNPGA or other specialized agreements) and BSM (for community sponsored FHTs). FHT are located across Ontario, in both urban and rural settings, ranging in size, structure, scope and governance.
Nurse Practitioner-Led Clinics (NPLCs) have been created throughout Ontario to provide comprehensive, accessible and coordinated family health care services by targeting Ontarians who have difficulty accessing primary care. NPLCs are contributing to a number of local and provincial health care priorities by providing faster access to care and collaborating with other community partners to improve quality and better coordinate care for their patients.
Community Health Centres (CHCs) are models of primary health care delivery that play a key role delivering primary health care services to priority populations across Ontario and support the province's overarching efforts to transform primary care. CHCs are not-for-profit community governed organizations with a primary focus to improve the health and well-being of populations who have traditionally faced barriers accessing health services, including those who are low income, new immigrants, those with complex mental health issues and individuals who do not have health insurance. CHCs are mandated to deliver comprehensive primary health care services, health promotion, and disease prevention services to individuals and families. CHCs develop partnerships that focus on broader health and social issues, such as inadequate housing, literacy, pollution, and other social determinants of health.
Indigenous Primary Health Care Organizations (IPHCOs) are Indigenous-governed primary health care organizations that provide a combination of traditional healing, primary care, cultural programs, health promotion programs, community development initiatives, and social support services to First Nations, Métis, and Inuit Communities. IPHCOs are closely modelled after Ontario's Community Health Centres and provide the mechanisms to improve the health and well-being of communities in Ontario facing various barriers in accessing health care. IPHCOs serve as a key contributor to Ontario's commitment to improve and expand access to comprehensive primary care by providing clinical care services, integrated chronic disease prevention and management, family focused maternal/child health care, and addictions counselling and mental health care.
Health Care Connect (HCC) refers Ontarians who are seeking a primary health care provider (family doctor or nurse practitioner) to a provider who is accepting new patients in their community. Insured persons without a primary health care provider who register with HCC may be referred to a family doctor or a nurse practitioner if there is a participating provider who is accepting new patients in their community. HCC is voluntary for both patients and providers and there is no guarantee that a referral will be made for each program registrant.
During 2021-2022, MOH continued to administer various initiatives to improve access to health care services across the province. Ontario's physician supply has been stable for the past number of years due to past medical school expansion. Nevertheless, Ontario's ongoing evidence-informed physician planning recently pointed to the need to adjust medical school enrolment to ensure ongoing and future stability. To that end, in March 2022, Ontario announced its plan to expand medical school education in the province, adding 160 undergraduate seats and 295 postgraduate positions over the next five years.
In addition to physicians, in Fall 2021, the province announced that Ontario would increase nursing education enrolment by adding 1000 new Registered Nurse and 500 new Registered Practical Nurse positions beginning Fall 2022 and Winter 2023.
Ontario also continues to work to enhance the retention and distribution of physicians through a range of measures, such as:
There are a number of existing initiatives to improve access across Ontario, including but not limited to the Northern and Rural Recruitment and Retention Initiative, the Northern Physician Retention Initiative, and the Northern Health Travel Grant Program.
Northern and Rural Recruitment and Retention Initiative (NRRRI): The NRRRI supports the recruitment and retention of physicians in rural and northern communities. The NRRRI provides financial recruitment incentives to physicians who establish a fulltime practice in an eligible community. Community eligibility for the NRRRI is based on a Rurality Index for Ontario score of 40 or more. Also eligible are the five Northern Ontario Urban Referral Centres (Thunder Bay, Sudbury, North Bay, Sault Ste. Marie, and Timmins).
Northern Physician Retention Initiative (NPRI): The NPRI provides physicians who have completed a minimum of four years of continuous full-time practice in Northern Ontario with a retention incentive paid at the end of each fiscal year in which they continue to practise full-time in Northern Ontario. NPRI supports retention of physicians in Northern Ontario and encourages them to maintain active hospital privileges. Northern Ontario is defined as the districts of Algoma, Cochrane, Kenora, Manitoulin, Nipissing, Parry Sound, Rainy River, Sudbury, Thunder Bay, and Timiskaming.
Northern Health Travel Grant (NHTG) Program: The NHTG Program helps defray travel-related costs for residents of Northern Ontario who must travel long distances to access OHIP insured medical specialist services, or ministry funded health care facility-based procedures that are not locally available, within a radius of 100 kilometres. In addition to travel grants based on kilometric rate, the program provides an accommodation allowance of $100-$550 (dependent on the number of lodging nights) per eligible treatment trip to patients whose one-way road distance to the nearest medical specialist able to render needed care is at least 200 kilometers. In 2017–2018, a $9.9 million enhancement was introduced to move from a $100 flat rate accommodation allowance to a maximum of $550, dependent on the number of medically necessary lodging nights. The NHTG Program also promotes using specialist services located in Northern Ontario, which encourages more specialists to practice and remain in the north.
Physicians are paid for the services they provide through a number of mechanisms. Many physician payments are provided through fee-for-service arrangements. Fee-for-service remuneration is based on the Schedule of Benefits - Physician Services a document incorporated by reference into Regulation 552 under the HIA. Other physician payment models include Primary Health Care Models (such as blended capitation models), Alternate Payment Plans, and funding arrangements for physicians in Academic Health Science Centres.
Physicians that belong to these other payment models may also bill fee-for-service when providing services that are outside of the scope of these models.
In fiscal year 2021, 97.93 per cent of General Practitioners received fee-for-service payments from OHIP, but fewer than 30 per cent of them were paid solely on a fee-for-service basis. The majority (65 per cent) of primary care physicians in Ontario received funding through one of the primary health models: Comprehensive Care (CCM), Family Health Group (FHG), Family Health Network (FHN), Family Health Organization (FHO), Community Health Centres (CHC), Rural and Northern Physician Group Agreement (RNPGA), Group Health Centre (GHC), Blended Salary Model (BSM) and specialized agreements.
The MOH negotiates physician compensation with the Ontario Medical Association (OMA) in accordance with the OMA Representation Rights and Joint Negotiation and Dispute Resolution Agreement. In 2017, the MOH and the OMA successfully negotiated a Binding Arbitration Framework, an agreement that governs the process for physician services agreement (PSA) negotiations, mediation, and arbitration.
On February 10, 2022, the MOH and OMA agreed to a memorandum of settlement for a new PSA establishing the parameters for physician compensation for the period of April 1, 2021 to March 31, 2024.
Ontario hospitals are funded through a combination of global funding, volume-based funding, and Patient-Based Funding—which provides funding on a spectrum between activity-based, and performance- based approaches.
Since April 1, 2012, Ontario shifted hospital funding from a predominantly global budget system towards a patient-based funding (PBF) system. PBF ensures that patients get the right care, at the right place, at the right time, and at the right price. PBF offers an integrated approach to health system funding and puts the patient at the centre through adopting a ‘funding follows the patient’ principle.
For purposes of funding, publicly funded hospitals are classified based on whether they receive funding through the Growth and Efficiency Model (GEM) or not. In addition, GEM hospitals are further classified based on whether they provide specialized care (e.g., teaching, pediatric) or by their size (e.g. large, medium).
Stand-alone psychiatric and small-sized hospitals do not receive GEM funding. Instead, they rely primarily on global budgets for their operational funding.
Hospital Funding Sources
Global funding: Non-targeted base funding that is carried over year-to-year. This funding is not tied to the delivery of specific procedures.
Growth and Efficiency Model (GEM) (Formerly Health-Based Allocation Model [HBAM]): HBAM was an evidence-based funding formula that used clinical and financial information to redistribute about $5.135 billion annually among all modeled hospitals, based on the number of patients treated and the complexity of their care. The model also took into account the efficiency of hospitals.
In 2019-2020, the redistribution of HBAM was suspended, pending development of a long-term plan that considers a consolidated approach to address growth in services, which resulted in the introduction of the Growth and Efficiency Model (GEM). GEM is used to allocate incremental growth funding, rather than re-distributing existing funds. This increases the total GEM funding envelope on an annual basis.
Quality Based Procedures (QBP): QBP are episodes of care (e.g., hip/knee replacement surgery, stroke) for which evidence-based best practices have been defined and providers are compensated for providing the services included in the episode based on an established price.
Funding is allocated by assigning a number of cases (volumes) and a provincial price that is specific to identified surgical or medical procedures. The provincial price is adjusted to reflect patient cohort differences at each hospital using a measure of acuity, known as the Case Mix Index (CMI).
The Ministry does not place a limit on the number of QBP services that can be provided. QBP volumes are targets based on historical activity and population growth needs. In this patient-based funding model, there is considerable flexibility for hospitals to perform additional (or fewer) volumes, in accordance with QBP volume management policies.
Bundled Care: Like QBP, Bundled Care funding is allocated by an assigned number of cases and a price. However, a Bundled QBP encompasses services that cross providers, specifically including hospital and post-acute community care like home and community care. Bundled QBP provide a single payment for an episode of care across multiple settings and providers, like hip/knee replacement surgery and post-surgical rehabilitation.
Funding is allocated to a Bundle Holder (a health service provider) who is responsible for partnering with and transferring funds to other service providers for surgical care and/or post- acute rehabilitation, providing a more integrated service from the time patients enter hospital for surgery to their recovery at home and in the community. Bundle Holders must ensure that patients are receiving the full scope of care in an integrated pathway, regardless of where the patient lives.
Bundled care is being implemented for hip and knee replacement surgery and chronic kidney disease, and being tested in other clinical areas.
Priority Programs and Services: Funding for life-saving procedures and specialized services (i.e., cardiovascular, neurosurgical, bariatric, critical care) as well as maternal/newborn health programs.
Funding rates are pre-set, and volume amounts are determined using a number of data points, including: historical utilization information, changes in the population of interest for the catchment area, and direct discussions with the hospitals and Ontario Health at the regional level , regarding their respective projections.
Post Construction Operating Plan (PCOP): PCOP funding provides operating funds to hospitals for clinical service and space expansions incurred after the completion of an approved capital project.
Post Construction Operating Plan funding may be provided for service volume increases, one-time start up and transition costs, equipment amortization and/or incremental facility costs.
Wait Times: Allocated to support additional diagnostic imaging (e.g. Magnetic Resonance Imaging [MRI] & Computerized Axial Tomography [CT] Hours) and select surgical procedures (price per procedure). Funding allocation is determined based on prior year performance, current capacity and wait lists and in-year reallocations.
Pay for Results (P4R): Provides annual one-time performance-related funding incentives to hospitals with high volume Emergency Departments with over 30,000 annual visits.
The Government of Ontario publicly acknowledged the federal contributions provided through the Canada Health Transfer in its Public Accounts of Ontario 2021-2022.
These estimates represent the number of Valid and Active Health Cards (have current eligibility and resident has incurred a claim in the last 7 years).
Return to footnote 1 referrer
Number represents all publicly funded hospitals excluding specialty psychiatric hospitals. Specialty psychiatric hospitals are excluded in order to conform to Canada Health Act Annual Report requirements.
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Amount represents funding for all public and private hospitals excluding specialty psychiatric hospitals.
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Data are not collected in a single system in MOH. Further, the MOH is unable to categorize providers/facilities as "for-profit" as MOH does not have financial statements detailing service providers’ disbursement of revenues from the Ministry.
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Indicators 10 & 11 include both in-patient and out-patient for insured hospital and physician services provided outside Canada.
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Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
Return to footnote 6 referrer
Data pertains to hospital services to out-of-country travellers for emergency services that are acute, unexpected, arose outside of Canada and require immediate treatment.
Return to footnote 7 referrer
Ontario has no non-participating physicians, only opted-out physicians who are reported under item #20
Return to footnote 8 referrer
Total payments includes payments made to Ontario physicians through Fee-for-Service, Primary Care, Alternate Payment Programs, Academic Health Science Centres, the Hospital On Call Program and Health Care Connect. Services and payments related to Other Practitioner Programs, Out-of-Country/ Out-of-Province Programs, Nurse Practitioners, Interprofessional Shared Care, NP Led Clinics, ECHO & Chronic Pain, Fertility Services, Family Health Teams and Community Labs are excluded.
Return to footnote 9 referrer
Data pertains to physician services for out-of-country travellers for emergency services that are acute, unexpected, arose outside of Canada and require immediate treatment.
Return to footnote 10 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.
Return to footnote 11 referrer
Manitoba Health provides leadership and support to protect, promote, and preserve the health of all Manitobans. MHSC continues efforts to improve access, service delivery, capacity, innovation, sustainability, and improve the health status of Manitobans while reducing health disparities. The roles and responsibilities of the department include policy, program and standards development; fiscal and program accountability; and evaluation. In addition, some direct services continue to be provided through Selkirk Mental Health Centre, Cadham Provincial Laboratory, public health inspections, and provincial nursing stations.
Manitoba Health formed the Diagnostic and Surgical Recovery Task Force (DSRTF) to address the COVID-19 related backlog in surgery and diagnostics. As well, under previously approved funding for addressing priority procedure wait times, nearly 8,000 surgical and diagnostic procedures were provided in 2021-2022 through the department's Request for Supply Arrangement (RFSA). These services were provided to Manitobans, through service procurement from multiple vendors, despite successive COVID-19 waves.
The Manitoba Health Services Insurance Plan (MHSIP) is administered by Manitoba Health under the Health Services Insurance Act, R.S.M. 1987, c. H35.
The MHSIP is administered under this Act, and insures the costs of hospital, personal care, medical and other health services referred to in acts of the legislature or related regulations.
The Minister of Health (the Minister) is responsible for administering and operating the MHSIP. The Minister may also enter into contracts and agreements with any person or group that he or she considers necessary for the purposes of the Act.
The Minister may also make grants to any person or group for the purposes of the Act on such terms and conditions that are considered advisable. Also, the Minister may, in writing, delegate to any person any power, authority, duty or function conferred or imposed upon the Minister under the Act or under the Regulations.
There were no legislative amendments to the Act or the Regulations in the 2021-2022 fiscal year that affected the public administration of the MHSIP.
Section 6 of the Health Services Insurance Act requires the Minister to have audited financial statements of the MHSIP showing separately the expenditures for hospital services, medical services, and other health services. The Minister is required to prepare an annual report, which must include the audited financial statements, and to table the report before the Legislative Assembly within 15 days of receiving it, if the Assembly is in session. If the Assembly is not in session, the report must be tabled within 15 days of the beginning of the next session.
Section 7 of the Health Services Insurance Act requires that the Office of the Auditor General of Manitoba (or another auditor designated by the Office of the Auditor General of Manitoba) audit the accounts of the MHSIP annually and prepare a report on that audit for the Minister. The most recent audit reported to the Minister and available to the public is for the 2021-2022 fiscal year and is contained in p. 137-139 here (www.gov.mb.ca/asset_library/en/proactive/20222023/public-accounts-2022.pdf).
Sections 46 and 47 of the Health Services Insurance Act, as well as the Hospital Services Insurance and Administration Regulation (M.R. 48/93), provide for insured hospital services.
There were no amendments to sections 46 and 47 of the Health Services Insurance Act or the Hospital Services Insurance and Administration Regulation in 2021-2022.
As of March 31, 2022, there were 96 facilities providing insured hospital services to both in-and out-patients. Hospitals are designated by the Hospitals Designation Regulation (M.R. 47/93) under the Act.
Services specified by the Regulation as insured in-patient and out-patient hospital services include:
The Regulation states that hospital in-patient services include routine medical and surgical supplies, thereby ensuring reasonable access for all residents. The regional health authorities and Manitoba Health (MH) monitor compliance.
No additional services were added to the list of insured hospital services in 2021-2022.
Manitoba Health for the period of 2021-2022, had no formal evidence, investigations or actions against any diagnostic clinics where there was an assertion of inappropriate charging of patients for services that would be considered insured if provided in a hospital. Manitoba Health and Seniors Care do not have any recent or upcoming legislative or regulatory changes in this regard.
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.
The enabling legislation that provides for insured physician services is the Medical Services Insurance Regulation (M.R. 49/93) made under the Health Services Insurance Act.
Physicians providing insured services in Manitoba must be lawfully entitled to practice medicine in Manitoba, and be registered and licensed under the Medical Act. As of April 30, 2022, there were 3,157 physicians registered in Manitoba, with 2,898 participating in the Manitoba Health Services Insurance Plan.
A physician, by giving notice to the Minister of Health (the Minister) in writing, may elect to collect the fees other than from the Minister for medical services rendered to insured persons, in accordance with section 91 of the Act and section 5 of the Medical Services Insurance Regulation. The election to opt out of the health care insurance plan takes effect on the first day of the month following a 90-day period from the date the Minister receives the notice.
Before rendering a medical service to an insured person, physicians must give the patient reasonable notice that they propose to collect any fee for the medical service from them or any other person except the Minister. The physician is responsible for submitting a claim to the Minister on the patient's behalf and cannot collect fees in excess of the benefits payable for the service under the Act or Regulations. No physicians opted-out of the medical plan in 2021-2022.
The range of physician services insured by Manitoba Health is listed in the Payment for Insured Medical Services Regulation (M.R. 95/96). Coverage is provided for all medically required personal health care services that are not excluded under the Excluded Services Regulation (M.R. 46/93) of the Act, rendered to an insured person by a physician.
During fiscal year 2021-2022, a number of new insured services were added to a revised fee schedule. The Physician's Manual can be found on the MH website.
The process for a medical service to be added to the list of those covered by MH is that physicians must put forward a proposal to their specific section of Doctors Manitoba. Doctors Manitoba will negotiate the item, including the fee, with MH. Manitoba Health may also initiate this process, which may include stakeholder and public consultation.
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, by giving to the minister at any time notice in writing, may elect to collect their fees directly from the patient in the same manner as physicians in accordance with section 91(1) of the Health Services Insurance Act 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 opted-out in 2021-2022.
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) for discussion with MH, which may include stakeholder and public consultation. The MDA negotiates the item and fee with MH.
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:
The Hospital Services Insurance and Administration Regulation states that hospital in-patient services includes routine medical and surgical supplies, thereby ensuring reasonable access for all residents. The regional health authorities and MH monitor compliance.
All Manitoba residents have equitable access to services. Third parties such as private insurers or the Workers Compensation Board do not receive priority access to services through additional payment. Manitoba has no formalized process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows regional health authorities and MH to monitor usage and service concerns.
To de-insure services covered by MH, 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 MH in 2021-2022.
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 of Health (the Minister) determines otherwise, or is a visitor, transient or tourist.
The Residency and Registration Regulation (M.R. 54/93) extends the definition of residency. The extensions are found in sections 7(1) and 8(1). Section 7(1) allows missionaries, individuals with out-of-country employment and individuals undertaking sabbatical leave to be outside Manitoba for up to two years while still remaining residents of Manitoba. Students are deemed to be Manitoba residents while in full-time attendance at an accredited educational institution. Section 8(1) extends residency to individuals who are legally entitled to work in Manitoba and have a work permit of 12 months or more under the Immigration and Refugee Protection Act (Canada). Additionally, section 8.1.1 of the Residency and Registration Regulation extends deemed residency to temporary foreign workers (and their dependents) in the province to provide agricultural services on the basis of a work permit, regardless of the duration of their work permit.
No amendments were made to the Residency and Registration Regulation (M.R. 54/93) in 2021-2022.
The Residency and Registration Regulation, section 6, defines Manitoba's waiting period as follows:
"A resident who was a resident of another Canadian province or territory immediately before his or her arrival in Manitoba is not entitled to benefits until the first day of the third month following the month of arrival."
Section 6 of the Residency and Registration Regulation stipulates that there is no waiting period for dependents of members of the Canadian Armed Forces.
There are currently no other waiting periods in Manitoba.
The Manitoba Health Services Insurance Plan (MHSIP) excludes residents covered under any federal plan, including the following federal statutes:
These residents become eligible for health services insurance coverage upon discharge from the Canadian Forces, or in the case of an inmate of a penitentiary, upon discharge if the inmate has no resident dependents. Upon change of status, these persons have one month to register with Manitoba Health (MH) (Residency and Registration Regulation [M.R. 54/93, subsection 2(3)])..
RCMP members are insured persons in Manitoba and are eligible for benefits under the MHSIP.
The process of issuing health insurance cards requires that individuals inform and provide documentation to MH that they are legally entitled to be in Canada, and that they intend to be physically present in Manitoba for six months in a calendar year. They must also provide a primary residence address in Manitoba. Upon receiving this information, Manitoba Health will provide a registration card for the individual and all qualifying dependents.
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 dependent. The six-digit number may be shared by all members of a family including a spouse and dependents. A nine-digit Personal Health Identification Number is used for payment of all medical service claims and hospital services.
As of March 31, 2022, there were 1,399,093 residents registered with the Manitoba Health Services Insurance Plan.
Individuals may appeal decisions of MH with respect to eligibility before the Manitoba Health Appeal Board, an independent quasi-judicial tribunal established pursuant to the Health Services Insurance Act.
There is no provision for a resident to opt out of the Manitoba Health Services Insurance Plan.
The Residency and Registration Regulation (M.R. 54/93, sub-section 8[1]) requires that temporary workers possess a work permit issued by Immigration, Refugees and Citizenship Canada for at least 12 consecutive months, be physically present in Manitoba for six months in a calendar year, and be legally entitled to be in Canada before receiving MHSIP coverage.
Section 8.1.1 of the Residency and Registration Regulation extends deemed residency to temporary foreign workers (and their dependents) in the province to provide agricultural services on the basis of a work permit, regardless of the duration of their work permit.
The Residency and Registration Regulation (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.
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 enrollment at any accredited educational institution. The additional requirement is that they intend to return and reside in Manitoba after completing their studies.
Manitoba has formal agreements with all Canadian provinces and territories for the reciprocal billing of insured hospital services.
In-patient costs are paid at standard rates approved by the host province or territory. Payments for in-patient, high-cost procedures, and out-patient services are based on national rates agreed to by provincial and territorial health plans. These include all medically necessary services as well as costs for emergency care.
Except for Quebec, medical physician services incurred in all provinces or territories are paid through a reciprocal billing agreement at host province or territory rates. Claims for physician medical services received in Quebec are submitted by the patient or physician to Manitoba Health for payment at host province rates.
The Residency and Registration Regulation (M.R. 54/93, sub-section 7[1]) defines the rules for portability of health insurance during temporary absences from Canada.
Section 7(1)(g) of the Residency and Registration Regulation extends the period during which a person may be temporarily absent from Manitoba for the purpose of residing outside of Canada from six months to a maximum of seven months in a 12-month period.
Residents on full-time employment contracts outside Canada will receive health services insurance coverage for up to 24 consecutive months. Individuals must return and reside in Manitoba after completing their employment terms. Individuals serving as humanitarian aid workers or missionaries on behalf of a religious organization approved as a registered charity under the Income Tax Act (Canada) will be covered by MH 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 MH for up to 24 consecutive months. These individuals also must return and reside in Manitoba after completing their leave.
Manitoba residents receiving coverage under the provincial health insurance plan who receive medical and hospital services outside of Canada are eligible to be reimbursed at the rates set out in the Medical Services Insurance Regulation and the Hospital Services Insurance and Administration Regulation. Emergency doctors’ services outside of Canada are reimbursed at a rate equal to what a Manitoba doctor would receive for a similar service. Emergency hospital care is paid on an average daily rate established by MH.
Prior approval is not required for procedures that are covered under the interprovincial reciprocal agreements with other provinces. Prior approval by MH is required for high cost items or procedures that are not included in the reciprocal agreements.
In order to be eligible for reimbursement, all non-emergency hospital and medical care provided outside Canada requires prior approval from MH. Manitobans requiring medically necessary medical and/or hospital services unavailable in Manitoba or elsewhere in Canada may be eligible for reimbursement of costs incurred outside of Canada, pursuant to the Medical Services Insurance Regulation, by providing MH with a recommendation from a specialist stating that the patient requires a specific, medically necessary service.
Individuals may appeal decisions of MH with entitlement to medical benefits before the Manitoba Health Appeal Board, an independent quasi-judicial tribunal established pursuant to the Health Services Insurance Act.
Manitoba Health ensures that medical services are equitable and reasonably available to all Manitobans. Effective January 1, 1999, the Surgical Facilities Regulation (M.R. 222/98) under the Health Services Insurance Act came into force to prevent private surgical facilities from charging additional fees for insured medical services.
The Health Services Insurance Act and the Private Hospitals Act include definitions and other provisions to ensure:
The Accessibility for Manitobans Act includes definitions and principles to ensure accessibility by preventing and removing barriers that disable people with respect to receiving health care services including:
In the event that a Manitoba resident feels that they have been inappropriately charged for a service that is insured under the provincial health insurance plan (i.e., a potential incidence of extra-billing or a user charge), the resident is encouraged to contact Manitoba to report this occurrence at the following:
Manitoba Health 300 Carlton Street Winnipeg, MB R3B 3M9 1-800-392-1207
Inquiries are made by the Insured Benefits Branch of MH into the specifics of the fee(s) charged to assess whether the service provided was an insured service, and any required further action. Generally, contact from MH to the medical service provider, advising that the provider must reimburse the patient and submit a claim to MH, is sufficient to address the concern. Further incidents on the part of the same service provider may result in an investigation by MH's Audit and Investigation Unit. Concerns regarding the professional conduct of medical service providers are referred to the appropriate regulatory agency.
Manitoba Health remains committed to the principles of Medicare and improving the health status of all Manitobans. In 2021-2022, Manitoba continued to support these commitments through a number of activities including the following:
System Transformation
Shared Health Manitoba, the provincial health organization announced in 2017–2018, continues to focus on patient-centred planning to ensure consistent standards across the province for the provision of care. Input was sought from over 10 provincial clinical teams comprised of health-care providers with varied professional backgrounds and experience across rural, urban and northern Manitoba communities which resulted in the publishing of a multi-year strategic plan, known as the Manitoba Clinical and Preventative Services Plan (MCPSP). The MCPSP is in the first wave of implementation planning, which lays the groundwork for future clinical shifts to better align services with population needs and bring health care services closer to home for Manitobans.
Manitoba continued to implement the patient centred medical home model through two complementary and aligned initiatives—MyHealth Teams and Home Clinic. The goal of these is to improve access and demonstrate achievement of quality primary care standards for Manitobans and to build a more integrated primary care system. Adoption rate of home clinics remained high, representing approximately 87.2 per cent of all primary care providers. Both initiatives remain aligned with the broader Manitoba Clinical and Preventive Services Plan.
Facilities
Manitoba Health provided strategic guidance for infrastructure investment to establish expectations and conditions to enable success for stakeholders to progress a cross-functional approach to planning and delivery of infrastructure including investments in repair, renovation and construction of buildings, specialized equipment and Information & Communications Technology (ICT).
Manitoba Health established a multi-year infrastructure plan that supports provincial population health objectives and is sustainable and sufficiently flexible to meet the changing needs of the population, and the requirements of innovation in service delivery. This included a review of prioritized requests for major capital and on-going repairs/replacement related to infrastructure, ICT and specialized equipment repairs and replacement received from regional health authorities (RHAs) / service delivery organizations (SDOs) as well as providing advice to inform government decision making for investment.
Manitoba Health planned, developed, and completed infrastructure based projects across the multi-year strategic capital plan to address the operation service needs of the provincial health system. For the 2021-2022 fiscal year, 94 individual investments within capital and ICT plus over 300 individual projects with the infrastructure repair and upgrades and specialized equipment categories. Projects with an estimated total project cost of $2.7 billion were submitted to MH and progressed.
Manitoba secured and sustained government funding to support the execution of the provincial strategic infrastructure/ICT capital plan that is defined and implemented in accordance with government direction and with regional need and best practices, appropriate standards (program, design and construction), approved scope and timeline, and negotiated costs limits. Oversight for the implementation of investments of approximately $292 million in infrastructure, ICT, and specialized equipment was provided.
Manitoba applied policies related to procurement practices, infrastructure development, infrastructure sustainment, departmental funding, and community cost-sharing and provided oversight and guidance to ensure that requirements were known to and complied with by RHAs and SDOs.
Manitoba provided efficient and accurate information on the department's infrastructure program including accurate forecasting of maintenance requirements, emerging program standards and models, capital financing and development of appropriate program and policy options.
Manitoba provided upgrades and functional changes to existing infrastructure in a timely, prioritized sequence and continued to oversee the annual ICT Infrastructure Renewal Program managed by Digital Health, which focuses on the execution of a risk-based approach to replacing and upgrading old, obsolete, and failing technical infrastructure in Manitoba's health information systems operating environment.
Policy, planning and project management oversight was provided to support department initiatives to ensure appropriate resourcing and solution delivery including significant efforts to update and sustain departmental ICT systems supporting critical administrative systems and information management and analytical capability. Manitoba provided necessary data and information for Health department staff to achieve corporate goals and objectives and consulted with other department branches/areas to ensure that all proposed projects fit with the department's planned priorities, as well as managing, maintaining, and providing security of the department systems and processes in support of user's access to information and in compliance with required availability targets.
Continued oversight for the annual safety and security program including the review of the prioritized list of potential projects from the regional health authorities / service delivery organizations and the monitoring of the projects to completion as well as the oversight of the annual specialized equipment program including monitoring expenditures and completion of delivery/installation.
Health Professionals
In 2021-2022, the province provided funding for the following complement of medical and nursing professionals registered to practice in Manitoba:
The transition to the Regulated Health Professions Act (RHPA) continues to be a significant undertaking for the province. The RHPA came into effect in January 2014 to ensure all regulated health professions are governed by consistent, uniform regulations with enhanced focus on patient safety and accountability. The legislation includes a list of activities and procedures called reserved acts, that regulated health professionals may be authorized to perform when providing health care based on their competence and training.
The RHPA sets out consistent rules and processes for governance, registration, complaints and discipline, as well as regulation and bylaw making authority. To date audiologists and speech language pathologists, physicians and surgeons, registered nurses, paramedics and registered psychiatric nurses have transitioned to regulation under the RHPA. It is expected that the professions of psychology and licensed practical nursing will be will be next professions to transition to regulation under the RHPA. The transition of other health professions to the RHPA will continue to be a focus for the province, as it will have a significant long-term impact on the provincial health workforce.
In 2021-2022, the province provided funding to increase the number of medical and nursing professionals registered in Manitoba as follows:
The number of Registered Nurses decreased by 136 (from 13,147 to 13,283).
Manitoba continues to employ the following methods of payment for physicians:
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 2021-2022 fiscal year.
Fee-for-service remains the primary method of payment for physician services. Alternate payment arrangements constitute a significant portion of the total compensation tophysicians in Manitoba. Alternate-funded physicians are those who receive non fee-for-service compensation, including through a salary (employment relationship) or those who work on an independent contract basis. Manitoba also uses blended payment methods where appropriate. As well, physicians may receive sessional payments for providing medical services on a time based arrangement, as well as stipends for on-call and other responsibilities.
In 2021-2022, Manitoba Health, in collaboration with Shared Health, represented Manitoba in its negotiations with Manitoba physicians. The physicians are typically represented by Doctors Manitoba with some exceptions, such as oncologists engaged by CancerCare Manitoba.
Doctors Manitoba and Manitoba reached a four-year agreement in July of 2019, to renew the physician Master Agreement. The new physician Master Agreement took effect on April 1, 2019, and will expire on March 31, 2023.
The Manitoba Physician's Manual lists all of the fee tariff descriptions, rates, rules of application and the dispute resolution process in relation to fee-for-service payments to physicians. This document is the Schedule of Benefits payable to physicians on behalf of insured persons in Manitoba pursuant to the Medical Services Insurance Regulation under the Health Services Insurance Act.
All fee-for-service claims must be submitted electronically. The submission of paper claims is permitted on a limited basis and only with the prior approval of MH. Fee-for-service claims must be received within six months of the date upon which the physician rendered the service.
Division 3.1 of Part 4 of the Regional Health Authorities Act sets out the requirements for operating agreements between regional health authorities and the operators of hospitals and personal care homes, defined as "health corporations" under the Act.
Pursuant to the provisions of division 3.1, regional health authorities are prohibited from providing funding to a health corporation for operational purposes unless the parties have entered into a written agreement for this purpose that:
If the parties cannot reach an agreement, the Act enables them to request that the Minister 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 required agreements with health corporations that enable the regional health authority to determine funding based on objective evidence, best practices and criteria that are commonly applied to comparable facilities. In all other regions, the hospitals are operated by regional health authorities. The allocation of resources by regional health authorities for providing hospital services is approved by MHSC through the approval of regional health plans, which the regional health authorities are required to submit for approval pursuant to section 24 of the Regional Health Authorities Act. Section 23 of the Act requires that regional health authorities allocate their resources in accordance with the approved regional health plan.
Pursuant to subsection 50(2.1) of the Health Services Insurance Act, payments from the Manitoba Health Services Insurance Plan for insured hospital services are to be paid to the regional health authorities. In relation to those hospitals that are not owned and operated by a regional health authority, the regional health authority is required to pay each hospital in accordance with any agreement reached between the regional health authority and the hospital operator.
No legislative amendments to the Act or the Regulations in 2021-2022 had an effect on payments to hospitals.
Manitoba regularly recognizes the federal role regarding the contributions provided under the Canada Health Transfer in public documents. Federal transfers are identified in the Supplement to the Estimates of Expenditures (Manitoba Budget) document and in the Public Accounts of Manitoba. Both documents are published annually by the Manitoba government.
Population as of June 1st.
Return to footnote 1 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
Return to footnote 2 referrer
The claims in our data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.
Return to footnote 3 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
Return to footnote 4 referrer
Saskatchewan's Ministry of Health is dedicated to achieving a responsive, integrated, and efficient health system for Saskatchewan people with a focus on better health, better care, better value, and better teams. The Ministry supports innovative approaches to meet the needs of patients and families by putting the patient first and enabling best possible health by promoting healthy choices and responsible self-care.
The provincial health care system focused on the ongoing challenges caused by the COVID-19 pandemic. Delivery of the largest vaccination efforts in the province's history continued throughout 2021, with a majority of residents receiving their first and second doses. There was also a major focus on restoring surgical and medical procedures, mental health and addictions services, and new investments in capital projects across the province.
Within Saskatchewan's health system, services are provided by the Saskatchewan Health Authority (SHA), the Saskatchewan Cancer Agency (SCA), the Athabasca Health Authority (AHA) and affiliated health care organizations, which are supported by eHealth Saskatchewan, 3S Health (Shared Services Saskatchewan), and a diverse group of professionals, many of whom are in private practice. There are 28 self-regulated health professions in the province, overseen by 26 regulatory bodies. An estimated 48,000 people provide a broad range of services across the health system.
The Ministry continues to assess how it is organized to provide effective strategic oversight for health system partners, and supports leadership from boards, management, and health professionals.
The Ministry maintains partnerships with local, regional, provincial, national and international organizations, to help ensure that all Saskatchewan residents have access to quality health care services.
The Government of Saskatchewan continues to work closely with health organizations, First Nations and Métis, the federal government, regulatory bodies, other provincial ministries, local governments and others in response to the COVID-19 pandemic.
The Ministry of Health implemented a range of measures to address backlogs in the system as a result of the COVID-19 pandemic, including:
The provincial government is responsible for funding and ensuring the provision of insured hospital, physician and surgical-dental services in Saskatchewan. Section 6.1 of the Health Administration Act authorizes that the Saskatchewan Minister of Health (the Minister) may:
Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act provide the authority for the Minister to establish and administer a plan of medical care insurance for residents of Saskatchewan. The Provincial Health Authority Act, implemented in 2017, provided the authority to amalgamate the 12 regional health authorities to a single health authority.
Sections 3 and 9 of the Cancer Agency Act provide the authority for establishing a Saskatchewan Cancer Agency and for the Agency to coordinate a program for diagnosing, preventing and treating cancer.
The mandates of the Saskatchewan Ministry of Health (the Ministry), provincial health authority, and the Saskatchewan Cancer Agency are outlined in the Health Administration Act, the Provincial Health Authority Act, and the Cancer Agency Act.
The Ministry of Health is directly accountable, and regularly reports, to the Minister on the funding, and administering the funds, for insured physician, surgical-dental, and hospital services.
Section 36 of the Saskatchewan Medical Care Insurance Act requires that the Minister submit an annual report concerning the medical care insurance plan to the Legislative Assembly.
The Provincial Health Authority Act requires that the provincial health authority submit to the Minister in each fiscal year:
Pursuant to legislation, the Minister submits these reports and corresponding statements to the Pursuant to legislation, the Minister submits these reports and corresponding statements to the Legislative Assembly.
Section 7-4 of the Provincial Health Authority Act requires that the provincial health authority and the Cancer Agency submit any reports that the Minister may request from time to time. The provincial health authority and the Cancer Agency are required to submit various financial documents and a health service plan to the Ministry.
The Office of the Provincial Auditor for Saskatchewan provides independent assurance (audit reports) and advice on the Government's management of and accountability practices for the public resources entrusted to it. The Provincial Auditor informs the Legislative Assembly about the reliability of the Government's financial and operational information, the Government's compliance with legislative authorities and the adequacy of the Government's management of public resources. Their reports are available on the Provincial Auditor of Saskatchewan web site. The most recent report was released June 7, 2022, and included examinations of the Saskatchewan Health Authority (SHA) and Health Shared Services Saskatchewan (3sHealth).
The Provincial Auditor conducts an annual audit of government ministries and agencies, including the Ministry. The audit of the Ministry includes a review of Ministry payments including, but not limited to, payments made to the SHA, the Saskatchewan Cancer Agency (SCA), and physicians and dental surgeons for insured physician and surgical-dental services.
Section 7-7 of the Provincial Health Authority Act requires that an independent auditor, who possesses the prescribed qualification and is appointed for that purpose by the SHA and the SCA, audit the accounts of the SHA or the SCA at least once in every fiscal year. The SHA and the SCA must annually submit to the Ministry a detailed, audited set of financial statements.
The most recent audits were for the year ending March 31, 2022. The SHA and SCA each table annual reports in the Saskatchewan Legislature each year which include their audited financial statements. The Government of Saskatchewan tables its audited financial statements (Public Accounts) in the Legislature each year as well. The reports are available to the public directly from each entity and are available on their websites. The annual reporting requirement for the provincial health authority are specified in section 7-5 of the Provincial Health Authority Act.
Section 2-7 of the Provincial Health Authority Act gives the Saskatchewan Minister of Health (the Minister) the authority to provide funding to the provincial health authority or a health care organization for the purpose of the Act. There were no amendments made to the Act in 2021-2022.
Section 2-9 of the Act permits the Minister to designate facilities including hospitals, special care homes and health centres. Section 2-10 allows the Minister to prescribe standards for delivering services in those facilities in the provincial health authority, including health care organizations that have entered into service agreements with the provincial health authority.
The Act sets out the accountability requirements for the provincial health authority and health care organizations. These requirements include, for example, submitting annual financial and health service plans for ministerial approval (section 7-2), and reporting critical incidents (section 8-2). The Minister also has the authority to establish a provincial surgical registry to help manage surgical wait times (section 2-11). The Minister retains authority to inquire into matters (section 8-3), appoint a public administrator if necessary (section 8-4), and approve general and practitioner staff by-laws (sections 6-1 to 6-3).
Funding for hospitals is included in the funding provided to the provincial health authority. A comprehensive range of insured services is provided by hospitals. These may include:
Hospitals are grouped into the following six categories: community or northern, district, regional, provincial, rehabilitation, and field. The hospitals are grouped this way so that people know what they can expect at each hospital. While not all hospitals will offer the same services, reliability and predictability means:
The provincial health authority has 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. Typically the provincial 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 service providers and the public.
The Patient Choice Medical Imaging Act and the Medical Imaging Facilities Licensing Regulations authorize private MRI and CT facilities in Saskatchewan to accept payment directly from patients in exchange for MRI and CT services. However, for every scan that is paid for privately, the Regulations require private providers to provide a second scan, free of charge, to an individual who is waiting on the public list. Private-pay CT and MRI service and its unique two-for-one provision gives patients more options in accessing CT and MRI service and has added capacity to the publicly-funded system at no extra cost to the health system or the patient receiving the reciprocal scan. Along with increases in public capacity, through expanded hospital volumes, new CT and MRI scanners, and increased volumes in publicly funded contracts, these privately funded scans and second scans are assisting in the management of diagnostic imaging wait times.
No new hospital services were added to the health care insurance plan in 2021.
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. There were no amendments to the Act in 2021-2022. All insured fee items for physicians can be found in the Physician Payment Schedule. As of March 31, 2022, there were 2,796 physicians licensed to practise in the province and eligible to participate in the Medical Care Insurance Plan. Of these, 1,416 (50.6 per cent) were family practitioners and 1,380 (49.4 per cent) were specialists. Physicians may choose not to participate in the Medical Services Plan (known in Saskatchewan legislation as opting-out), but if doing so, they must fully opt out of providing any insured physician services. As per legislation, the non-participating 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 they understand the advice given by the physician is also required.
As of March 31, 2022, there were no non-participating physicians in Saskatchewan.
Insured physician services are those that are medically necessary, are covered by the Medical Services Plan of the Saskatchewan Ministry of Health, and are listed in the Physician Payment Schedule as prescribed by the Saskatchewan Medical Care Insurance Payment Regulations, 1994 of the Saskatchewan Medical Care Insurance Act.
A process of formal discussion and negotiation between the Ministry's Medical Services Branch and the Saskatchewan Medical Association addresses new insured physician services and definition or assessment rule revisions to existing insured physician services. The Executive Director of the Medical Services Branch manages this process. When the Medical Services Plan covers a new insured physician service, or a change is made to an existing physician service, the changes are reflected in the Physician Payment Schedule. A regulatory amendment to the Saskatchewan Medical Care Insurance Payment Regulations, 1994 is required to provide the authority to pay updated rates to physicians and new insured services.
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.
Dentists may choose to not participate in the Medical Services Plan, but if doing so, they must opt out of providing any insured surgical-dental services. The non-participating 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, or advise the beneficiaries to seek services from a dental specialist who is participating. Written acknowledgement from the beneficiary indicating that they or she understands the advice given by the dentist is also required.
There was one non-participating general and specialist dentist in Saskatchewan as of September 13, 2022.
Insured surgical-dental services are limited to:
In addition, all dental anaesthetic for beneficiaries under age 14 is publicly funded.
Surgical-dental services can be added to the list of insured services covered under the Medical Services Plan through a process of negotiation with provincial dental surgeons. The Executive Director of the Medical Services Branch manages the process of adding a new service. Although formal public consultations are not held, any member of the public may recommend that surgical-dental services be added to the Medical Services Plan.
As of September 13, 2022, there were approximately 630 practicing dentists and dental surgeons located in all major centres in Saskatchewan. Seventy provided services insured under the Medical Services Plan.
Uninsured hospital, physician and surgical-dental services in Saskatchewan include:
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. There are no charges allowed in Saskatchewan for insured hospital, physician, or surgical-dental services. Charges for enhanced medical services or products are permitted only if the medical service or product is not deemed medically necessary and/or not deemed to be an insured service. Compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as via complaints from members of the public.
Insured hospital services are typically de-insured by the government if they were determined to be no longer medically necessary and/or clinically appropriate. The process involves discussions among stakeholders, practitioners, and officials from the Saskatchewan Ministry of Health.
Insured physician services could be de-insured if they were determined not to be medically required and/or clinically appropriate. The process involves 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 and/or clinically appropriate. The process involves discussion and consultation with the dental surgeons of the province, and is managed by the Executive Director of the Medical Services Branch.
Formal public consultations about de-insuring hospital, physician or surgical-dental services may be held if warranted. There were no services de-insured during 2021-2022.
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.
While the Regulations set out classes of beneficiaries exempt from insured services under the Act, it is possible for individual residents to request that the Health Registry not issue a provincial health card in certain cases (e.g., for religious reasons).
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. There were no changes to residency requirements in 2021-2022.
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 covered under Saskatchewan's Medical Services Plan:
Such people become eligible for coverage as follows:
Individuals who are not successful when applying for a provincial health card may appeal the decision by submitting to Health Registries - eHealth Saskatchewan, a Saskatchewan Health Services Card Application—Appeal Form.
The number of persons registered for health services in Saskatchewan on June 30, 2021, was 1,209,615.
Other categories of individuals who are eligible for insured health service coverage include persons allowed to enter and remain in Canada under authority of a work permit, study permit, or Minister's permit issued by Immigration, Refugees and Citizenship Canada. Their accompanying family may also be eligible for insured health service coverage.
Refugees are eligible on confirmation of Convention status or with a study or work permit, Minister's permit, or permanent resident or landed immigrant record.
People moving to Saskatchewan from outside of Canada may be eligible for Saskatchewan health coverage on, or before, the first day of the third month after arriving in Canada, if among one of the following groups:
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 initial arriving spouse is established on either 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. The second spouse would be eligible on the first day of the third month following arrival.
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.
Residents of Saskatchewan are able to maintain health coverage during a period of temporary absence, conditional upon the registrant's intent to return to Saskatchewan residency.
In 2015–2016, Saskatchewan amended the Medical Care Insurance Beneficiary and Administration Regulations to increase the amount of time residents are allowed to be out-of-province while still maintaining their health care benefits. Residents are now able to maintain health coverage after spending a maximum of seven months outside of Saskatchewan. Residents were only allowed to be absent for a maximum of six months over any 12 month period before their health benefits were discontinued. The amended legislation took effect January 1, 2016.
Section 6.6 of the Health Administration Act provides the authority for paying in-patient hospital services to Saskatchewan beneficiaries temporarily residing outside the province. Section 10 of the Saskatchewan Medical Care Insurance Payment Regulations, provides payment for physician services to Saskatchewan beneficiaries temporarily residing outside the province but within Canada. No amendments were made to the Act in 2021-2022; however, amendments were made to the Regulations to provide the authority to pay updated rates and new insured services to physicians.
Saskatchewan has bilateral reciprocal billing agreements with all provinces for hospital services. Quebec does not participate in reciprocal billing of physician services.
Section 3 of the Medical Care Insurance Beneficiary and Administration Regulations of the Saskatchewan Medical Care Insurance Act prescribes the portability of health insurance provided to Saskatchewan residents who are temporarily absent from Canada.
Residents of Saskatchewan are able to maintain health coverage during a period of temporary absence, conditional upon the registrant's intent to return to Saskatchewan residency.
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 five months physical presence requirement because the nature of their employment requires travel from place to place outside Canada (e.g., cruise line workers).
Section 6.6 of the Health Administration Act provides the authority under which a resident is eligible for health coverage when temporarily outside Canada. In summary, a resident is eligible for medically necessary hospital services at the rate of $100 per in-patient and $50 per out-patient visit per day. No amendments were made to the Regulations in 2021-2022.
Out-of-Province
The Saskatchewan Ministry of Health covers most hospital and medical out-of-province care received by its residents in Canada through reciprocal billing arrangements. These arrangements mean that residents do not need prior approval and may not be billed for most hospital and medical services received within the publicly funded health care system in other provinces or territories while travelling within Canada. The cost of travel, meals and accommodation are not covered. Prior approval is required for the following services provided out-of-province:
Prior approval from the Saskatchewan Ministry of Health must be obtained by the patient's specialist before the out-of-province services are received.
Out-of-Country
If a specialist physician refers a patient outside Canada for treatment not available in Saskatchewan or another province, the referring specialist must obtain prior approval for coverage from the Medical Services Plan of the Saskatchewan Ministry of Health. The Saskatchewan Cancer Agency is consulted for out-of-country cancer treatment requests. If approved, the Saskatchewan Ministry of Health will pay the full cost of treatment, excluding any items that would not be covered in Saskatchewan.
In Saskatchewan, the Health Services Review Committee (HSRC) is an arms-length panel that reviews government decisions made on requests for out-of-province and out-of-country medical coverage, ensuring legislation, policy, and guidelines are followed appropriately.
The Ministry of Health informs eligible applicants of their right to request a review by the HSRC upon denial of their out-of-province or out-of-country coverage request. A person can request a review by the HSRC only if the coverage request was for out-of-province insured medical health services, elective out-of-country insured medical services (physician and hospital care) or community care programs (mental health, alcohol and drug, problem gambling, and rehabilitative services).
If a case is ineligible for HSRC or if HSRC upholds the Saskatchewan Ministry of Health's coverage decision, a person may contact the Provincial Ombudsman for their review.
To ensure that access to insured hospital, physician, and surgical-dental services is 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.
Pursuant to section 18 (1.1) of the Saskatchewan Medical Care Insurance Act, no physician or other person who provides an insured service to a beneficiary shall demand or accept payment for that service in an amount that he knows exceeds the payment to be made for that service prescribed in the Saskatchewan Medical Care Insurance Payment Regulations.
With regard to extra-billing and user charges, compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as complaints from members of the public. The Saskatchewan Ministry of Health's General Inquiry contact information is as follows:
Saskatchewan Ministry of Health [email protected]
When requests are made by a beneficiary to reimburse monies paid directly to a physician for insured physician services that are extra-billing charges, correspondence is sent to the beneficiary (copying the physician) advising them of section 18 (1.1) of the Saskatchewan Medical Care Insurance Act that a physician must accept the negotiated rate as payment in full for insured services provided to a beneficiary. Once they have received payment from Medical Services Plan for the eligible service(s), reimbursement for any difference in the amount charged by the practitioner and the amount paid by Medical Services should be collected directly from the practitioner. If further complaint is made, the beneficiary is directed to address complaints to the Saskatchewan College of Physicians and Surgeons.
In addition, a private third-party facility must obtain a health facility license to provide certain insured services (e.g., surgical services) on behalf of the publicly funded health system. The Health Facilities Licensing Act (HFLA) authorizes and prescribes the conditions under which a health facility license may be issued to a private facility. The HFLA stipulates that a licensee may not charge or permit any other person to charge any fee to any beneficiary for any insured health service as defined under the HFLA.
Legislation prescribes that the Saskatchewan Minister of Health may amend, suspend or cancel a license if, in the opinion of the Minister, the licensee has failed to comply with the above clause.
Persons who have a complaint of an extra-billing and user charge may also raise the concern with the College of Physicians and Surgeons of Saskatchewan. The College has in their bylaws 7.1 Code of Ethics that includes:
Contravention of, or failure to comply with, the Code of Ethics is unbecoming, improper, unprofessional or discreditable conduct for the purposes of the Saskatchewan Medical Care Insurance Act.
The health system continues to strengthen coordination, communication, and referral guidelines to better coordinate services to ensure patients have timely access to the most appropriate specialist and diagnostic services. By reducing the wait time for a consult with a specialist or diagnostic services (such as MRI and CTs), patients will be able to access treatment sooner.
Other Programs and Initiatives to Improve Access
The Family Physician Comprehensive Care Program is intended to support recruitment and retention of family physicians by recognizing those physicians who provide a full range of services to their patients and the continuity of care that result from these comprehensive services.
Leveraging Immediate Non-Urgent Knowledge (LINK) is a provincial telephone consultation service that allows primary care providers to consult with a specialist about serious and/or complex non-urgent patient health concerns. LINK helps patients get answers to their health concerns sooner, prevents unnecessary referrals, and supports better referrals to the right specialist when required.
Specialist's wait times can vary for a variety of reasons and can result in two patients with the same condition and acuity having very different wait times. Pooled referrals offer referring physicians and their patients more choices to reduce wait times and improve patient access. Pooled referral systems direct patients to the next available specialist able to treat the patient's condition yet still allow physicians to make direct referrals to a specific specialist using the same referral process.
Saskatchewan's online Specialist Directory makes it easier to find current surgical wait times and information about surgical specialists in Saskatchewan. It can help patients and their family doctors view their options for surgical services and help them to easily identify the most appropriate surgeon for them. One of the many benefits is it can enable patients who are willing to travel to have the surgery more quickly in a location other than their nearest surgical centre.
Section 6 of the Saskatchewan Medical Care Insurance Payment Regulations, 1994 outlines the obligation of the Minister of Health to make payments for insured services in accordance with the Physician Payment Schedule and the Dentist Payment Schedule.
Fee-for-service is the most widely used method of compensating physicians for insured health services in Saskatchewan, although sessional payments, salary, and blended methods are also used. Fee-for-service is the only mechanism used to fund dentists for insured surgical-dental services. Total expenditures for in-province physician services and programs in 2021-2022 amounted to $1.178 billion: $541.9 million for fee-for-service billings; $33.8 million for Specialist Emergency Coverage Programs; and $488.2 million in non-fee-for-service expenditures. There was also an additional $114.6 million for the Clinical Services Fund and other Saskatchewan Medical Association and bursary programs.
The Saskatchewan Joint Medical Professional Review Committee (JMPRC) is a physician peer-review Committee that was established by section 49 of the Saskatchewan Medical Care Insurance Act (1988) to review the billing patterns of Saskatchewan physicians who are directly billing the publicly funded system for insured services. The JMPRC reviews billing patterns of physicians referred by the Director of Professional Review of the Ministry of Health and in cases where they determine that monies have been paid by the Minister inappropriately, they may order recovery from the physician.
Saskatchewan physicians do not charge block fees.
Funding to the SHA takes into account status quo funding levels and is adjusted for inflation, utilization increases, collective agreement increases, new programs and other adjustments as outlined in the current year provincial budget. The SHA 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. The SHA may receive additional funds for providing specialized hospital programs and services (e.g., pandemic response, acute services, organ and tissue donation, emergency medical services, surgical, and mental health and addictions services).
Payments to the SHA for delivering services are made pursuant to section 2-7 of the Provincial Health Authority Act. The legislation provides the authority for the Minister of Health to make grants to the SHA 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.
The SHA provides an annual report on the consolidated financial results of its operations.
Federal contributions provided through the Canada Health Transfer are publicly acknowledged by the Government of Saskatchewan in:
These documents were tabled in the Legislative Assembly and are publicly available to Saskatchewan residents at Saskatchewan.ca. Federal contributions have also been acknowledged in news releases and issue papers, and in speeches and remarks made at various conferences, meetings, and public policy forums.
Saskatchewan's numbers as of June 30.
Return to footnote 1 referrer
As reported by the Saskatchewan Health Authority in their annual audited financial statements.
Return to footnote 2 referrer
CT and MRI services are not considered insured services in Saskatchewan within the meaning of the Saskatchewan Medical Care Insurance Act. Private facilities providing surgical, MRI and CT services may receive payments for these services under contract with the provincial health authority. The Ministry of Health does not directly provide payments to these facilities.
Return to footnote 3 referrer
Data for prior years has been re-stated to reflect total number of hospital cases rather than claims as a single hospitalization can result in numerous claims.
Return to footnote 4 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
Return to footnote 5 referrer
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.
Return to footnote 6 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.
Return to footnote 7 referrer
While responding to the challenges presented by the pandemic, Alberta's Ministry of Health continued to pursue opportunities to strengthen Alberta's publicly funded health care system, improve service delivery, and support better outcomes. In 2021-2022, the Government of Alberta invested in high priority areas including addressing surgical wait times, and providing mental health and addiction supports. More information about the Ministry is available through the Ministry of Health website.
Throughout 2021-2022, Alberta responded to COVID-19, including supporting the care of Albertans in the face of rising hospitalizations (ICU and non-ICU). In line with other provinces, it became necessary to postpone non-emergent or non-urgent publicly funded surgeries at times.
By August 2021, 80 per cent of surgeries postponed since March 2020 were completed, and by March 2022, Alberta was providing close to normal surgical volumes.
The Government of Alberta remains committed to ensuring all Albertans receive their required surgeries within clinically recommended wait times by increasing capacity through post-pandemic surgical recovery plans and the Alberta Surgical Initiative (ASI). The objective of this initiative is to decrease wait lists and strengthen the entire publicly funded surgical system from referral at primary care, to screening and referral wait times, to specialists and clinics through surgery and rehabilitation.
Although the ASI is specifically addressing surgery, improvements in referral management will have a positive effect on reducing wait times for referrals for all specialists.
In 2021-2022, $4.2 billion was allocated to hospital-based in-patient services, including ASI operating funding of $58 million. The Budget 2021 Capital Plan also included ASI capital projects at Alberta Health Services (AHS)-owned facilities in Calgary, Edmonton, Edson, Grande Prairie, Lethbridge, Medicine Hat and Rocky Mountain House.
An integral part of the ASI is to increase volumes of publicly funded surgeries at no cost to patients through Chartered Surgical Facilities (CSF). CSFs continued to provide publicly funded surgeries as hospitals diverted resources to treat COVID-19 and emergency conditions. A record number (approximately 51,500) of publicly funded surgeries were completed in CSFs in 2021-2022. Since January 2021, there has been growth in CSF capacity as AHS expanded contracts with current CSF operators to include orthopedics, and increased volumes for ophthalmology, ear, nose, and throat procedures, publicly funded plastic surgery, and dermatology. New contracts between AHS and CSF operators have been planned or implemented for ophthalmology and orthopedics.
The Ministry of Health has committed to adding up to 50 permanent, fully staffed ICU beds as part of a $300 million investment over three years to expand health care capacity. These ICU beds will expand Alberta's health care capacity to help manage potential future waves of COVID-19 and reduce the strain on the system at peak times even in "normal" years.
Cancer screening programs (breast, cervical, and colorectal) were also impacted by the COVID-19 pandemic and are now increasing capacity to address decreased participation that occurred in 2020-2021. While significant improvements have been made to ensure procedures for high-risk patients are completed first, it is estimated that it will take up to three years to bring screening rates back up to pre-pandemic levels.
Alberta pharmacists are compensated for clinical pharmacy services provided to Albertans under an enhanced scope of practice, the broadest in Canada. These pharmacist services reduced pressures on acute care and primary care providers in the health care system, including during the COVID-19 pandemic.
The Ministry of Health also took steps to strengthen its health care workforce to improve overall capacity and mitigate against the impacts of the pandemic. Undergrad nursing employees were provided with extended opportunities, such as working on in-patient units with a critical nursing shortage. Moreover, the Ministry of Health provided an exemption to the Continuing Care Health Service Standards to allow Alberta nursing students and health care aides educated outside of Alberta to begin working while waiting to have their substantial equivalent assessment completed.
To address the growing demand on Emergency Medical Services (EMS) and provide immediate and long-term recommendations, the Ministry of Health has created an EMS advisory committee. Further, the Shock Trauma Air Rescue Service, the Helicopter Emergency Response Organization, and the Helicopter Air Lift Operation Air Ambulance each received record funding to ensure quality and timely access to emergency services for rural Albertans.
The Ministry of Health sets policy and direction to achieve a sustainable and accountable health system to promote and protect the health of Albertans. The Ministry of Health administers and operates the Alberta Health Care Insurance Plan (AHCIP), in accordance with the Canada Health Act. Since 1969, the Alberta Health Care Insurance Act (AHCIA), which is available on the Alberta King's Printer website, has regulated the administration and operation of the AHCIP. Section 3 of the AHCIA establishes the AHCIP and designates the Alberta Minister of Health (the Minister) as the public authority responsible for the administration and operation of the AHCIP.
The Minister is accountable for the AHCIP. As the public authority responsible for the administration and operation of the AHCIP, the Minister is required to administer and operate the AHCIP on a non-profit basis, in accordance with the AHCIA and the regulations, to provide benefits for basic health services to all residents of Alberta. The AHCIA and regulations include a number of accountability measures relating to the administration and operation of the AHCIP, including provisions that enable the Minister to reassess claims for benefits and recover overpayments to practitioners.
The Fiscal Planning and Transparency Act (FPTA), which is available on the Alberta King's Printer website, provides a framework for government budgeting and fiscal planning. A ministry annual report is prepared under the direction of the Minister in accordance with the FPTA and the government's accounting policies. The Ministry of Health 2021-2022 Annual Report, covering the fiscal year April 1, 2021 to March 31, 2022, was released on June 28, 2022.
The Auditor General of Alberta is an independent office responsible for conducting annual financial audits and other audits pertaining to the government's management of public resources. In accordance with Alberta's Auditor General Act, audit reports are tabled with the Legislative Assembly. The Auditor General's opinion on the audit of the Government of Alberta's consolidated financial statements, which includes the financial transactions and other information of the Ministry of Health, was published on June 28, 2022, in the Government of Alberta's 2021-2022 Annual Report.
The report indicated that the consolidated financial statements present fairly, in all material respects, the financial position and results of operations, in accordance with the Canadian public sector accounting standards, for the fiscal year ended March 31, 2022.
The Hospitals Act, the Operation of Approved Hospitals Regulation (247/1990), the Hospitalization Benefits Regulation (AR 244/1990), the Health Facilities Act (HFA), and the Health Facilities Regulation (AR 208/2000) govern the provision of insured services in hospitals and chartered surgical facilities (CSF). These are available on the Alberta King's Printer website.
In Alberta, Alberta Health Services (AHS) is an entity accountable to the Minister for ensuring the provision of insured hospital services. The publicly funded hospital services provided in approved hospitals in Alberta include all of the hospital services listed in the Canada Health Act. The insured hospital services range from advanced levels of diagnostic and treatment services for in-patients and out-patients, to routine care and management of patients with previously diagnosed chronic conditions. The benefits available to hospital patients in Alberta are set out in the Hospitals Act and the Hospitalization Benefits Regulation.
The list of insured services included in the Hospitals Act and the Hospitalization Benefits Regulation is intended to be both comprehensive and generic, thereby limiting the need for routine review and updating. No new insured hospital services were added during 2021-2022.
Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) diagnostic procedures are publicly funded and provided to eligible Albertans by AHS at an AHS facility or AHS contracted facility. AHS has a system that sets priorities and manages wait times. If a patient chooses to attend a private diagnostic clinic and self pay, AHS has a process for reimbursement if certain criteria are met.
AHS maintains a policy to reimburse patients for any medically required CT and MRI diagnostic procedures purchased privately from one of the community diagnostic imaging operators. The Ministry of Health has not made any legislative or regulatory changes affecting insured hospital services in 2021-2022.
The Alberta Health Care Insurance Act (AHCIA) establishes the Alberta Health Care Insurance Plan (AHCIP) to provide benefits for basic health services to all residents of Alberta. Physicians, as defined in the AHCIA, are permitted to claim benefits through the AHCIP for providing insured services. Persons referred to in section 20.1 of the AHCIA (discussed further below) are also able to submit claims for benefits through the AHCIP for insured services provided by physicians, subject to meeting certain legislative requirements.
Section 20.1 of the AHCIA authorizes a person (excluding individuals and professional corporations) to submit claims for benefits for an insured service provided by a physician if:
Examples of possible section 20.1 persons include AHS, or a corporation that owns and operates pharmacies.
The person referred to in section 20.1 has a direct legal relationship with the Minister through the section 20 agreement or arrangement (i.e., a legal right to claim and receive benefits for the provision of insured services by a physician without the physician having to assign the benefits to that person).
Section 20.1(4) provides that the person referred to in section 20.1 has all the duties of a physician with respect to the provision to the Minister of information required to facilitate the handling, assessing, and payment of the claim for benefits. The person referred to in section 20.1 is also subject to the prohibition on extra-billing, the Minister's right to recover amounts, and monitoring and enforcing compliance with the AHCIA. In 2021-2022 there were no section 20 arrangements or agreements with a person referred to in section 20.1.
Alberta had 10,816 physicians who claimed benefits under the AHCIP as of March 31, 2022. Within this amount:
A physician must complete the appropriate registration forms and include a copy of the licence issued to them by the College of Physicians and Surgeons of Alberta (CPSA) before being registered with the AHCIP.
Under section 8 of the AHCIA, all physicians are deemed to participate in the AHCIP. Under section 8(2), a physician may choose to not participate in the AHCIP by taking the following actions at least 180 days prior to the effective date of opting out:
Legal requirements are set out in section 8(3) of the AHCIA for a physician who has not previously practised in Alberta and wants to opt out of the AHCIP. Under section 8(3), the physician may choose to not participate in the AHCIP prior to commencing practice by:
By not participating in the AHCIP, a physician agrees that, commencing on the effective date of opting out, they will not participate in the publicly funded health system. This means that the physician cannot submit a claim for benefits to the AHCIP for payment for providing what would otherwise be insured health services, and the patient cannot seek reimbursement for any amounts paid by the patient for receiving health services from the non-participating physician.
The Medical Benefits Regulation (AR 84/2006) establishes the benefits payable for insured medical services provided to a resident of Alberta. Descriptions of those insured services which are payable on a fee-for-service basis are set out in the Schedule of Medical Benefits.
The Ministry of Health is committed to having a Schedule of Medical Benefits that supports continuous improvement and is responsive to health reform. The medical community is consulted by engaging with the Alberta Medical Association (AMA), and health services codes are created to ensure the Schedule of Medical Benefits reflects the current standard of practice within Alberta. There is no broader public consultation. All changes to the Schedule of Medical Benefits require the approval of the Minister of Health.
Virtual care health service codes were added to the Schedule of Medical Benefits to ensure continuation of essential medical services during the COVID-19 pandemic. These virtual care codes were made permanent in the Schedule of Medical Benefits on June 9, 2020. Enhancements to the virtual care health service codes are being made on an ongoing basis, as required.
In May 2021, the Ministry of Health formed a virtual care working group to explore short-term opportunities with respect to virtual care compensation. The group included members from AHS, AMA and CPSA. Based on the working group's recommendations, the Ministry of Health made enhancements to the Schedule of Medical Benefits in respect of virtual codes in January 2022. The changes allow billing of a single complex modifier for complex cases as well as time spent on patient management activities. Further, since February 2022, changes also allow billing for time spent on indirect patient care for virtual psychiatric consultations and for discussing a child's psychiatric treatment with their parent or guardian.
Two health service codes added in 2020-2021 to the Schedule of Medical Benefits for the administration of the COVID-19 immunization remain. The two health service codes include determination of appropriate candidacy of the patient for the vaccination, general discussion with the patient, obtaining consent, administration of a single dose, updating the patient's immunization record, and scheduling a second vaccine dose. In addition, the COVID-19 Vaccine Awareness Program was introduced in targeted areas where vaccine uptake was less than 50 per cent to support physicians to pro-actively engage with their patients and encourage COVID-19 vaccine uptake. Eligibility since expanded to all Alberta physicians.
In Alberta, a small number of medically necessary oral surgical and dental procedures are insured through the ACHIP, and are listed in the Schedule of Oral and Maxillofacial Surgery Benefits. In 2021-2022, no updates were made to this schedule.
The majority of dental procedures for which benefits are claimed through the AHCIP can only be performed by a dentist certified as an oral and maxillofacial surgeon who meets the requirements stated in the AHCIA. Insured dental-surgical services must be performed in either a public hospital or a CSF. Major surgical services, including dental-surgical services as referred to in section 2(2)(b) of the HFA may only be provided in a public hospital. As of March 31, 2022, there were 189 dentists participating under the AHCIP for eligible dental procedures and no dentists were opted-out of the AHCIP. Routine dental care is not an insured service for which a benefit is payable through the AHCIP.
Although there is no formal agreement with dentists, the Ministry of Health meets with the Alberta Dental Association to discuss changes to the Schedule of Oral and Maxillofacial Surgery Benefits. There is no public consultation. All changes to the Schedule of Oral and Maxillofacial Surgery Benefits require the approval of the Minister of Health.
Under section 7(1) of the AHCIA, all dentists are deemed to participate in the AHCIP. Under section 7(2), a dentist may opt out of the AHCIP by taking the following actions at least 30 days prior to the effective date of opting out:
Legal requirements are set out in section 7(3) of the AHCIA for a dentist who has not previously practised in Alberta and wants to opt out of the AHCIP. Under section 7(3), the dentist may choose to not participate in the AHCIP prior to commencing practice by:
By choosing to not participate in the AHCIP, a dentist agrees that, commencing on the effective date of opting out, they will not participate in the publicly funded health system. This means that the dentist cannot submit a claim for benefits to the AHCIP for payment for providing what would otherwise be insured surgical-dental services and the patient cannot seek reimbursement for any amounts paid by the patient for receiving surgical-dental services from the non-participating dentist.
Section 4(2) of the Hospitalization Benefits Regulation provides a list of hospital services that are not insured services.
The Preferred Accommodation and Non-Standard Goods or Services Policy (Policy) describes the Government of Alberta's expectations of AHS and guides the provision of preferred accommodation and enhanced or non-standard goods and services. The Policy requires AHS to provide 30 days’ advance notice to the Minister of Health's designate regarding the categories of preferred accommodation offered and the charges associated with each category. AHS is also required to provide 30 days’ advance notice to the Minister of Health's designate regarding any goods or services that will be provided as non-standard goods or services. AHS must also provide information about the associated charge for these goods or services, and when applicable, the criteria or clinical indications that may qualify patients to receive it as a standard good or service. Alberta's Preferred Accommodation and Non-Standard Goods or Services Policy is available online.
Section 12(2) of the Alberta Health Care Insurance Regulation (AR 76/2006) lists services that are not considered basic or extended health services unless otherwise approved by the Minister of Health. Section 4(2) and section 5(2) of the Oral and Maxillofacial Surgery Benefits Regulation (AR 86/2006) indicates no benefits are payable for oral and maxillofacial surgery services provided to an Alberta resident in another province or territory of Canada or outside of Canada if the services provided are not insured services in Alberta.
Services not covered by the AHCIP include (but are not limited to):
Health services are deleted from the Schedule of Medical Benefits when those services are identified by the medical community as obsolete. The process to engage the medical community is completed through consultation with the AMA and AHS. The AMA is the representative for each physician section. AHS is engaged in this decision process in order to understand how changes may impact current service delivery models or the health system at a macro level. No services were removed in 2021-2022.
Pursuant to the Alberta Health Care Insurance Act and the Hospitals Act, Alberta residents are eligible to receive insured services under the Alberta Health Care Insurance Plan (AHCIP) and the Hospitalization Benefits Plan. There were no changes made to eligibility requirements in 2021-2022.
A resident is defined as a person who is lawfully entitled to be or to remain in Canada, who makes the province their home and is ordinarily present in Alberta, and any other person deemed by the regulations to be a resident. The term "resident" does not include a tourist, transient, or visitor to Alberta.
Persons moving permanently to Alberta from outside Canada are eligible for coverage if they have permanent resident status, are returning permanent residents, or are returning Canadian citizens. Persons residing in Alberta on an approved Canada entry document may also be eligible for coverage, and their eligibility is reviewed on a case-by-case basis.
A resident is not entitled to coverage if the resident is a member of the Canadian Armed Forces or a person serving a term of imprisonment in a federal penitentiary as defined in the Corrections and Conditional Release Act. These residents receive health care coverage from the federal government. Spouses or partners and dependants of these residents are provided with coverage if they are Alberta residents.
Individuals released within Alberta from the Canadian Armed Forces or federal penitentiaries, are eligible for coverage effective the date of release, if notified within three months. If individuals are released in another part of Canada, they are eligible for coverage on the first day of the third month after becoming a resident of Alberta.
In order to access insured services under the AHCIP and the Hospitalization Benefits Plan, Alberta residents are required to register themselves and their eligible dependants. Family members are registered on the same account. Persons moving to Alberta should apply for coverage within three months of arrival or effective dates may be affected. For persons moving to Alberta from within Canada, their registration is effective on the first day of the third month after they become an Alberta resident. For persons moving to Alberta from outside Canada, their registration is effective the day they become an Alberta resident. The process for registering Albertans requires registrants to provide documentation that proves their identity, legal entitlement to be in Canada, and Alberta residency.
When a cancellation or denial of AHCIP or Hospitalization Benefits Plan coverage is questioned, an individual may contact the Ministry of Health by phone, e-mail, or mail to discuss the issue. If the issue cannot be resolved by front-line staff, it is escalated to a supervisor, then a manager, if needed. The manager will conduct a thorough investigation and send a letter with reasons for the decision, as it relates to legislation.
Individuals can choose to not participate in the AHCIP by filing a "Declaration of Election to Opt Out" at any time for themselves and their dependants. Coverage is cancelled for 36 months or until the declaration is revoked by the individual. A new declaration is required every 36 months of non-participation. Individuals may also choose to assume the entire responsibility for the payment of the costs of the individual's hospital services.
As of March 31, 2022, there were 4,913,180 Alberta residents registered with the Ministry of Health for coverage through the AHCIP and the Hospitalization Benefits Plan. A total of 255 Alberta residents were non-participants.
Under the Alberta Health Care Insurance Regulation, a person may be deemed a resident for the purpose of AHCIP coverage if they are residing in Alberta to work, study, or are the spouse, partner or dependant of someone who is here to work or study. A similar deeming provision exists in the Hospitalization Benefits Regulation whereby a person who is in full-time attendance at an education institute, but whose ordinary place of residence is outside of Canada, is deemed to be a resident if they intend to remain in Alberta for a period of 12 consecutive months. A Canada Entry Document such as a Work Permit or Study Permit, is required as proof of their legal entitlement to be, and remain, in Canada. Dependants accompanying temporary residents on a Work or Study Permit must have a Visitor Record (that limits the length of stay) as proof of their legal entitlement to be, and remain, in Canada. Deemed residents must intend on residing in Alberta for 12 months or more. AHCIP coverage is provided to temporary residents and their accompanying dependants who meet all the eligibility requirements. There were 72,588 people covered by the AHCIP under these conditions as of March 31, 2022.
Individuals who hold a Study Permit that does not indicate a school in Alberta are required to provide proof of registration from the accredited school they are attending. Open or employer-specific Work Permits must be valid for six months or more. Employer-specific Work Permits must state a company operating in Alberta employs the individual. With the exception of clergy, athletes or members of the British army, individuals with a Visitor Record must be the spouse, partner, or dependant of an eligible resident or deemed resident.
Individuals with a Canada Entry Document that has the remark 'does not confirm resident status', are not eligible for AHCIP coverage. Permanent Residents who have proof of Permanent Resident Status and Convention Refugees who have a positive Notice of Decision letter are eligible for AHCIP coverage. Refugee claimants are not eligible.
Children of non-entitled residents (e.g., residents on a Visitor Record, with expired permits, or refugee claimants) who were born in Canada and meet residency requirements are eligible for AHCIP and Hospitalization Benefits Plan coverage. Children born to Canadian citizens who are temporarily absent from Alberta (and have maintained their coverage) are also eligible; however, documentation may be required.
Seasonal workers from outside Canada are considered Temporary Foreign Workers. To obtain AHCIP coverage, they must meet the definition of deemed resident, have a Work Permit as proof of their legal entitlement to be, and remain, in Canada and intend on residing in Alberta for 12 months or more. Seasonal workers from other provinces retain health coverage from their home province.
Returning Canadians whose Alberta residency has expired must provide evidence of their legal entitlement to be, and remain, in Canada (typically a permanent resident card) and meet residency requirements to be eligible for AHCIP and Hospitalization Benefits Plan coverage. Individuals who have applied for Permanent Resident status must maintain legal entitlement to be, and remain in Canada, (e.g., a valid Work Permit, Study Permit or Visitor Record) while they await a decision on the Permanent Resident application. During this period, AHCIP coverage may be granted if they meet the eligibility requirements for a deemed resident.
Under the Alberta Health Care Insurance Plan (AHCIP) and the Hospitalization Benefits Plan, generally, persons moving permanently to Alberta from another part of Canada are eligible for coverage on the first day of the third month following the date they establish residency in Alberta.
The AHCIP provides coverage under the Alberta Health Care Insurance Regulation for eligible Alberta residents who temporarily leave Alberta for other parts of Canada. There is a similar provision in the Hospitalization Benefits Plan for coverage for insured hospital services.
A person is considered temporarily absent from Alberta if the person stays in another province or territory for a period that does not exceed 12 consecutive months and where the person intends to return to and maintain permanent residence in Alberta on the conclusion of their stay outside Alberta. Albertan students who attend an accredited school in Canada, and who intend to return to Alberta after completing their studies, maintain their AHCIP and Hospitalization Benefits Plan coverage.
Temporary Foreign Workers who are deemed residents retain their AHCIP coverage if they travel to another Canadian province for vacation; however, they do not retain their coverage if they leave Alberta to work in another province or if they leave Canada.
Individuals who are routinely absent from Alberta every year normally must spend a cumulative total of 183 days in a 12-month period in Alberta to maintain continuous coverage. Individuals not present in Alberta for the required 183 days may be considered residents of Alberta if they satisfy the Ministry of Health of their permanent and principal place of residence within the province. Individuals may also remain eligible for coverage if, on a recurring basis, they are absent from Alberta for up to 212 days in a 12-month period for the purpose of vacation.
The Ministry of Health participates in Interprovincial Hospital and Medical Reciprocal Billing Agreements. All provinces and territories participate in Hospital Reciprocal Agreements, and all provinces and territories, except Quebec, participate in Medical Reciprocal Agreements. These agreements were established to minimize complex billing processes and to help ensure timely payments to physicians and hospitals when they provide services to residents from other provinces or territories. Under the agreements, where an eligible Albertan receives an insured physician service or hospital service in another participating province or territory, Alberta will reimburse for the insured service provided at the host province's or territory's rates for medical services and the applicable rate for hospital services.
In 2021-2022, no amendments were made to the legislation regarding portability within Canada. More information on coverage during temporary absences outside Canada is available online.
Section 16(1)(a) of the Hospitalization Benefits Regulation addresses payment for goods and services provided outside of Alberta but in Canada to in-patients and out-patients in hospitals. Section 4 of the Medical Benefits Regulation addresses payment of medical services provided by a physician outside of Alberta but within Canada. These sections were not amended in 2021-2022.
Pursuant to the Alberta Health Care Insurance Regulation, eligible Alberta residents who are temporarily absent from Canada are covered through the AHCIP. There is a similar provision in the Hospitalization Benefits Regulation.
A person is considered to be temporarily absent from Alberta if the person stays outside Canada for a period that does not exceed six consecutive months, and the person intends to return to and maintain permanent residence in Alberta on the conclusion of their stay outside Alberta.
Individuals who are routinely absent from Alberta every year normally must spend a cumulative total of 183 days in a 12-month period in Alberta to maintain continuous coverage. Exceptions may be considered by the Ministry of Health depending on the individual circumstance. Individuals may also remain eligible for coverage if, on a recurring basis, they are absent from Alberta for up to 212 days in a 12-month period for the purpose of vacation.
Individuals leaving the province temporarily on extended vacations, or for temporary employment, may be eligible for coverage for 24 to 48 consecutive months. Students attending an accredited educational institute outside Canada on a full-time basis are entitled to coverage for the duration of their studies providing they intend to reside in Alberta at the conclusion of their studies.
The maximum amount payable for out-of-country in-patient hospital services is $100 CAD per day (not including day of discharge). The maximum hospital out-patient visit rate is $50 CAD, 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 $544 CAD per visit, with a limit of one visit per day. Physician and dental specialist or oral surgeon services are paid according to Alberta rates as per the Schedule of Medical Benefits.
The AHCIP does not provide coverage for non-urgent health services received by Albertans when travelling in another country. Only claims for emergency physician and/or hospital services received outside of Canada are eligible for reimbursement. Section 12(2)(I) of the Alberta Health Care Insurance Regulation provides that services provided outside Canada that are available inside Canada (other than services provided in the case of an emergency resulting from an acute and unexpected illness, disease, condition or injury that requires medically required treatment without delay outside Canada) are not insured services. Similarly, section 4(2)(e.1) of the Hospitalization Benefits Regulation provides that services provided by a facility outside of Canada (other than services provided in the case of an emergency resulting form an acute and unexpected illness, disease, condition or injury that requires medically required treatment without delay outside Canada) without the prior approval of the Minister are not insured services.
Funding may also be available through the Out-of-Country Health Services Committee. The Committee reviews applications for payment of expenses for insured medical services and insured hospital services to be provided outside of Canada when:
The Committee is governed by the Out-of-Country Health Services Regulation when making decisions for payment of such expenses. The Committee can only approve applications that satisfy the application criteria and timelines as set out in the Out-of-Country Health Services Regulation.
Decisions made by the Out-of-Country Health Services Committee can be appealed. An appeal may be submitted by an Alberta physician or dentist on behalf of the Alberta resident or by the Alberta resident to the Out-of-Country Health Services Appeal Panel (Appeal Panel). The Appeal Panel can only review the information provided in the application to the Out-of-Country Health Services Committee and cannot review any new information. The Appeal Panel has the authority to confirm, vary or substitute the Out-of-Country Health Services Committee's decision.
The Out-of-Country Health Services Committee and Out-of-Country Health Services Appeal Panel were established under the Alberta Health Care Insurance Regulation, and continues under the Out-of-Country Health Services Regulation (MO 78/2006).
More information on coverage during temporary absences outside Canada is available online.
Section 16(1)(b) of the Hospitalization Benefits Regulation addresses payment for goods and services provided to residents of Alberta by hospitals or approved facilities outside of Canada. Section 5 of the Medical Benefits Regulation addresses payment of benefits for medical services provided to residents of Alberta by physicians outside Canada. These sections were not amended in 2021-2022.
Prior approval is not required for elective (non-emergency) insured services in another Canadian province or territory that would be billed under the interprovincial hospital and medical reciprocal agreements. Prior application is required for elective services received in another Canadian province or territory for new and emerging procedures that are not covered under the interprovincial hospital and medical reciprocal agreements for insured services that are medically required, are not experimental, and are not available in Alberta. Prior application is also required for elective services rendered out-of-country and approval may only be given through the Out-of-Country Health Services Committee for insured services that are medically required, are not experimental, and are not available in Alberta or elsewhere in Canada.
Decisions made by the Out-of-Country Health Services Committee can be appealed. An Alberta physician or dentist on behalf of the Alberta resident or the Alberta resident may submit appeals. The Out-of-Country Health Services Appeal Panel was established under the Alberta Health Care Insurance Regulation, and continues under the Out-of-Country Health Services Regulation (AR 78/2006). The Out-of-Country Health Services Appeal Panel reviews the application, the Out-of-Country Health Services Committee's decision, and determines whether to confirm, vary or substitute the Out-of-Country Health Services Committee's decision under appeal.
The Government of Alberta is committed to meeting the health care needs of all Albertans. To ensure Albertans have the best possible access to primary health care services, the Ministry of Health funds Primary Care Networks (PCN). Physicians and Alberta Health Services (AHS) are jointly responsible for PCNs through joint venture agreements. In most cases, the physicians’ non-profit corporation and AHS enter into a joint venture agreement whereby they agree to operate the PCN. In a small number of cases, AHS and the physicians enter into a joint venture agreement and form a non-profit corporation to operate the PCN. In both cases, the Ministry of Health provides grant funding for the operations of the PCN.
PCNs support inter-disciplinary teams made up of family physicians and other health care professionals who deliver primary health care services for their patients. Each PCN has the flexibility to develop programs and provide services to meet the specific needs of patients. Access to health care services can be limited by geography, hours of operation, and wait times. As of March 31, 2022, there were 40 PCNs operating in Alberta. More than 3.8 million Albertans were attached to a PCN. A total of 5,052 primary care providers (including family physicians, pediatricians, and nurse practitioners), and the full-time equivalent of 1,249 other health care providers were registered providers in PCNs.
Section 9(1) of the Alberta Health Care Insurance Act (AHCIA) prohibits extra-billing by opted-in physicians or dentists [i.e., physicians and dentists participating in the Alberta Health Care Insurance Plan (AHCIP)]. No physician or dentist who participates in the AHCIP and who provides insured services to a resident with coverage under the AHCIP is allowed to charge or collect from any person an amount in addition to the benefits payable by the Minister of Health for those insured services. Section 9(1.1) of the AHCIA contains a similar prohibition for persons referred to in section 20.1 of the AHCIA.
Section 11 of the AHCIA prohibits any person from charging or collecting from any person the following payments, where the amount is in addition to the benefits payable by the Minister of Health for the insured service:
When an individual questions extra-billing or user charges, they may contact the Ministry of Health staff by phone, e-mail, fax, or mail as follows: Alberta Health
Attention: Alberta Health Care Insurance Plan PO Box 1360, Stn Main Edmonton AB T5J 2N3Phone: Edmonton: 780-427-1432; Toll free in Alberta: 310-0000 then 780-427-1432Fax: 780-422-0102E-mail: [email protected] (This email address is for general information or non-personal questions regarding the AHCIP)
If the matter cannot be resolved with the physician or dentist through communication or education, it may proceed to a compliance review.
The Ministry of Health monitors and enforces compliance with the AHCIA through a dedicated compliance unit. The unit reviews billing compliance, recovers inappropriately paid funds, and educates on appropriate billing practices. These reviews are conducted pursuant to section 18 of the AHCIA. If a compliance review uncovers evidence of non-compliance with sections 9 or 11 of the AHCIA, then sections 9, 11, 12, 13, and 14 set out the fines and other steps that may be taken by the Minister of Health.
Sections 9(2), 9(2.1), and 9(3) set out the escalating disciplinary actions the Minister may take in response to extra billing, in addition to any actions taken under sections 13 and/or 14.
Section 11(3) authorizes the Minister to recover from any person who receives a prohibited fee, that amount in a civil action in debt. Where the Minister recovers an amount pursuant to section 11(3), section 11(4) requires the Minister to reimburse the recovered amount to the person who was charged the amount.
Section 12(1) establishes that a physician or dentist who is opted into the AHCIP and provides insured services in circumstances where the physician or dentist knows, or reasonably ought to have known, that a person has been charged an amount in contravention of section 11 shall not receive payment of benefits from the Minister for those insured services.
Section 12(1.1) contains a similar prohibition on receiving benefits for a person referred to in section 20.1. Section 12(2) then provides that if benefits have been received in contravention of sections 12(1) or 12(1.1), the sanctions set out in section 9(2) of the AHCIA apply.
Section 13 of the AHCIA sets out the Minister's right to recover amounts received in contravention of sections 9, 10, or 12 by one or more of the following means:
Section 13(3) provides that the Minister must reimburse a person in respect of whom benefits may be paid for any amounts recovered under section 13 that were paid by the person and have not been previously reimbursed.
Section 14 provides that a contravention of sections 9, 10, 11, or 12 is an offence and subject to the fines set out in section 14.
To ensure Albertans have access to safe and appropriate health care services during the COVID-19 pandemic, Alberta's Ministry of Health committed to expanding virtual care and digital solutions. Health Canada supports part of this work under a bilateral agreement for approximately $16 million and an agreement with Canada Health Infoway for $2 million.
The Ministry of Health has identified four strategic priorities for virtual-care delivery in Alberta:
Health infrastructure is critical to ensuring current and future health care needs are met. The Ministries of Health and Infrastructure share responsibility for planning and management of Alberta's Health Capital Plan and projects.
The Ministry of Health is responsible for setting strategic directions and implementing health policy, legislation, standards and providing global operating funding to AHS. AHS identifies and prioritizes health service needs requiring capital development. The Government of Alberta supports health infrastructure by funding capital development and the Infrastructure Maintenance Program.
The Ministry of Infrastructure is responsible for the design, construction and delivery of major health capital projects throughout the province. The Ministry of Health provides capital grants to support private organizations – such as continuing care and addictions and mental health operators – with infrastructure needs, typically through competitive capital grant programs that incentivize infrastructure development in line with strategic needs while ensuring best value for money. The Regional Health Authorities Act and the Hospitals Act also stipulate requirements for the purchase and disposition of assets and properties and the general provisions for health infrastructure.
The Budget 2021 Capital Plan dedicated $2.6 billion over three years for capital investments in health care, including $2.2 billion for major capital projects and programs like the state-of-the-art Calgary Cancer Centre, the Alberta Surgical Initiative (ASI), and several continuing care facility projects. The Budget 2021 Capital Plan also included $343 million for capital maintenance and renewal of existing facilities, and $90 million for health IT projects. The Budget 2021 Capital Plan included funding for new projects such as a new Maternity and Community Health Centre in the northern community of La Crete, a cyclotron facility to create important radiopharmaceuticals in Calgary, and redevelopment of the Rockyview General Hospital's Intensive Care Unit, Coronary Care Unit and Gastrointestinal Clinic.
The Rural Health Facilities Revitalization Program continues to fund renovations and upgrades in smaller health facilities in rural communities throughout the province, while the Medical Equipment Replacement and Upgrade Program enables the procurement of modern diagnostic and treatment equipment for AHS.
In the 2021-2022, approximately $927 million was spent on health infrastructure and equipment.
The AHCIA governs the payment of claims of benefits for the provision of insured medical services by physicians to eligible Alberta residents. In Alberta, the College of Physicians and Surgeons of Alberta (CPSA) enforces standards of practice for physicians charging for uninsured professional services (services which are not insured under the AHCIA), which include rules related to block billing by physicians.
Under the Oral and Maxillofacial Surgery Benefits Regulation (AR 86/2006), benefits are payable in accordance with the regulations under the AHCIA for oral and maxillofacial surgery services provided to a resident of Alberta by a dentist.
Physicians are compensated through the AHCIP on a volume-driven, fee-for-service basis or through the use of alternative compensation models, which are authorized by section 20 of the AHCIA. Examples of alternative compensation models include Clinical Alternative Relationship Plans (ARP) and the Alberta Academic Medicine and Health Services Program master agreements. Some primary care physicians are compensated through a "Blended Capitation Model" which allows physicians to submit certain fee-for-service claims and receive capitation payments though a Clinical ARP.
Clinical ARPs and the Alberta Academic Medicine and Health Services Program master agreements provide alternative compensation models to the traditional fee-for-service basis of compensation. Their purpose is to enhance physician recruitment and retention, team-based approaches to service delivery, access to services, patient satisfaction, and value for money. They also support innovative health care delivery, which will result in better health outcomes. The more predictable funding provided through Clinical ARPs and the Alberta Academic Medicine and Health Services Program master agreements enables physician groups to recruit new physicians and retain their services to support service delivery.
Through Clinical ARPs, the Minister compensates physicians for delivering a defined set of insured medical services to a specific patient population (e.g., people diagnosed with Chronic Obstructive Pulmonary Edema). On March 31, 2020, a Clinical ARP was established to compensate physicians redeployed to provide care to COVID-19 patients.
There are two Alberta Academic Medicine and Health Services Program master agreements, which include the University of Alberta in the "north sector" master agreement and the University of Calgary in the "south sector" master agreement. The master agreements are multi-party, including the Minister of Health, AHS, the participating physicians, and the respective university. The master agreements include accountability and reporting requirements for AHS, the universities, and the participating physicians. Key performance themes include clinical service delivery, administration and leadership, research productivity, and educational quality. These themes are used to measure performance on an annual basis.
The Government of Alberta and the Alberta Medical Association (AMA) have a long-standing relationship in the form of formal agreements. The Ministry of Health continued to work with physicians and the AMA to address common interests such as quality of care, health care system sustainability, and stability of physician practices. Discussions on a formal agreement continued to progress throughout the 2021-2022 fiscal year.
To ensure accountability with the AHCIA, the Ministry of Health conducts regular reviews of claims filed by physicians, for their compliance with the AHCIA. The Ministry of Health uses statistical and risk assessment methodologies to identify errors or issues in the claims that were paid under the AHCIP. Compliance reviews can be initiated for a practitioner or group of practitioners to determine compliance with specific legislative or contractual requirements. Further, a compliance review may be triggered by a specific complaint about a physician from an external party.
Alberta's public hospitals are operated by AHS or by non-profit organizations under service agreements with AHS. In Alberta, public hospitals are operated in accordance with the Hospitals Act and regulations. The Health Facilities Act (HFA) prohibits the operation of private hospitals.
The Regional Health Authorities Act governs the funding of AHS, Alberta's single regional health authority. The Ministry of Health funds AHS through base operating funds provided twice each month. AHS determines funding for individual hospitals and the facility fees for operators of chartered surgical facilities (CSF) that are contracted by AHS to provide insured surgical services.
The Hospitals Act and the HFA govern the provision of insured and uninsured surgical services performed in public hospitals and CSFs. The HFA prohibits queue jumping for insured surgical services. Specifically, no person shall give or accept any money or other valuable consideration, pay for or accept payment for enhanced medical goods or services or non-medical goods or services, or provide an uninsured surgical service for the purpose of giving any person priority for the receipt of an insured surgical service. Access to insured surgical services is based on the medical needs of patients and determined by physicians and dentists.
The Minister of Health must approve any proposed service agreement between an operator of a CSF and AHS in order for insured surgical services to be provided in the operator's CSF. The CSF must also be designated by the Minister and accredited by the CPSA.
According to the HFA, the Minister may not approve a proposed agreement between AHS and a CSF operator unless:
Pursuant to the terms of the agreement between AHS and the operator of the CSF, AHS agrees to pay the operator a "facility fee". This fee covers the overhead costs of the facility, such as equipment and staffing. Physicians who provide insured surgical services to patients within an accredited CSF are paid through the AHCIP. The amount paid to the physician is the same regardless of whether the physician provides the insured surgical service in a public hospital setting or in a CSF.
The Government of Alberta publicly acknowledged the federal contribution provided through the Canada Health Transfer in the 2021-2022 Government of Alberta Annual Report.
Data reported reflect claims processed up to three months after the close of the fiscal year. Any claims processed after this date are not reflected in the presented information.
Return to footnote 1 referrer
These data do not include claims/payments for Alberta residents who have received health services through the Out-of-Country Health Services Committee application process.
Return to footnote 2 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.
Return to footnote 3 referrer
The claims in our data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.
Return to footnote 4 referrer
Data for this section reflect claims processed up to three months after the close of the fiscal year. Any data pertaining to expenditures and physicians processed after this date are not reflected in the presented information.
Return to footnote 5 referrer
The physician count includes physicians who are paid on fee-for-service basis, or through the use of alternative compensation models, which are authorized by section 20 of the Alberta Health Care Insurance Act.
Return to footnote 6 referrer
Of the 10,816 participating physicians, 8,754 were paid exclusively on a fee-for-service basis, 1,047 were paid solely through an agreement or arrangement under section 20 of the AHCIA (i.e., either through one of the Academic Medicine and Health Services Program master agreements or through an Alternative Relationship Plan) and the remaining 1,015 received compensation on both a fee-for-service basis and through an agreement or arrangement authorized by section 20 of the Health Care Insurance Act.
Return to footnote 7 referrer
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.
Return to footnote 8 referrer
These data do not include Alberta residents who have received health services through the Out-of-Country Health Services Committee application process. Additionally, following a methodology change in 2015-2016, there is a one-year lag from fiscal year end to date of payment for out-of-country data. This means data for out-of-country physician services are still being processed for 2021-2022.
Return to footnote 9 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.
Return to footnote 10 referrer
The claims in our data system cannot be separated into pre-approved or non pre-approved, therefore, the numbers reflect the total claims and payments as reported for previous years.
Return to footnote 11 referrer
Alberta's legislation provides that all dentists 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 7 of the Alberta Health Care Insurance Act.
Return to footnote 12 referrer
British Columbia (BC) has a progressive and integrated health care system, which includes a health care insurance plan that provides publicly funded health care services to residents of BC in accordance with the guiding principles of the Canada Health Act. The BC Ministry of Health (the Ministry) has overall responsibility for ensuring that quality, appropriate, and timely health care services are available to all British Columbia residents.
To read more about BC's publicly-funded health system, please refer to the Ministry of Health's 2021-2022 Service Plan (PDF, (506 kb).
The COVID-19 public health emergency continued in effect throughout the reporting period (and was still in effect as of March 31, 2022) and enables public health orders. The provincial state of emergency for COVID-19 ended at 11:59 pm on June 30, 2021.
The Province of British Columbia (BC) took precautions and steps necessary to protect people, communities, and the most vulnerable from COVID-19 throughout the reporting period. While not exhaustive, the following information identifies key highlights of work during this time to protect British Columbians and contribute to a safer and healthier province and country. Key COVID-19 measures are highlighted below:
The Ministry sets goals, standards and performance expectations to deliver on provincial health care system services and public health priorities. The Ministry works with the six health authorities throughout the province to provide quality, appropriate, equitable, timely, and cost-effective health services to British Columbians. There are five regional health authorities that deliver health care services to meet the needs of the population within their respective geographic regions. A sixth health authority, the Provincial Health Services Authority (PHSA), is responsible for provincial clinical policy, the delivery of provincial clinical services, provincial commercial services and provincial digital and information management and information technology planning and services. The Ministry works in partnership with the First Nations Health Authority (FNHA) to collaboratively support First Nations health and wellness in British Columbia. FNHA supports the health and wellness of First Nations people in British Columbia, and is responsible for planning, management, service delivery and funding of First Nations health programs, in partnership with First Nations communities. The Ministry also collaborates with and provides funding supports for other Indigenous service partners, including the British Columbia (BC) Association of Aboriginal Friendship Centres which focuses on the urban Indigenous population, and Métis Nation BC which addresses the needs of Métis peoples and communities.
The BC Medical Services Plan (MSP), which is managed by the Medical Services Commission (MSC) on behalf of the Government of BC, provides health care coverage (including for diagnostic services) to beneficiaries and corresponding payments to medical and health care practitioners.
MSP is administered pursuant to the Medicare Protection Act (MPA). The purpose of the MPA is to preserve a publicly managed 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. It expressly incorporates the principles of the Canada Health Act.
The MSC reports to the Minister of Health (the Minister), in accordance with the MPA. Under the MPA, the function and legislative mandate of the MSC is to facilitate reasonable access, throughout British Columbia, to quality medical care, health care, and prescribed diagnostic services for British Columbians.
The MSC is a nine-member statutory body comprised of three representatives of the Government of British Columbia, three representatives from the Doctors of BC (referred to as the BC Medical Association in the MPA, the organization's registered legal name), and three members from the public who have been jointly nominated by the Doctors of BC and the Government of British Columbia to represent beneficiaries.
General hospital services are publicly funded in British Columbia under the Hospital Insurance Act, the Hospital Insurance Act Regulations, the Hospital Act, and Hospital District Act.
Medically required laboratory services (including in-patient and out-patient laboratory testing) are publicly funded under the Laboratory Services Act (LSA). The Minister is responsible for all matters related to laboratory services (including the test review and facility approval processes), governance, accountability, and provision of benefits for all laboratory services in BC. On June 29, 2018, the Minister delegated the delivery of certain operational functions (under the LSA) to Provincial Laboratory Medicine Services (previously the BC Agency for Pathology and Laboratory Medicine), a program under the PHSA. The PHSA's mandate is to provide effective provincial oversight, which includes provincial planning, coordination, monitoring, evaluating, and reporting on province-wide results and health outcomes for publicly funded laboratory and pathology services.
The Ministry provides information on the performance of British Columbia's publicly-funded health care system in its Service Plan Report (PDF, 527 kb). Tracking and reporting this information is consistent with the Ministry's strategic approach to performance planning and reporting, and it is consistent with requirements contained in the provincial Budget Transparency and Accountability Act.
The MSC is accountable to the Government of British Columbia through the Minister. The MSC Annual Report, which provides an annual accounting of the business of the MSC, its advisory committees and other delegated bodies, is published annually for the prior fiscal year.
Regional health authorities and the PHSA have independent boards; however, the Boards are accountable to the Minister and are required to follow directions from the Minister or report to the Minister for required stewardship purposes. The Board Chairs receive mandate letters from the Minister, which are posted publicly on each health authority's website. All health authorities are expected to develop information that clearly describes their goals, objectives, and strategies.
The Ministry's accounts and financial transactions are subject to audit as follows:
The OAG's annual audit of the Ministry's accounts and financial transactions are reflected in the OAG's overall review and opinion related to the BC Public Accounts, which can be found on the Government of BC website. The OAG's special audits and reports can be located on the Office of the Auditor General of BC website.
Since 2005, the Ministry has contracted with MAXIMUS Canada to deliver many of the administrative operations of MSP (the province's medical insurance plan) and PharmaCare (the province's drug insurance plan), including responding to public inquiries, registering clients, and processing medical and pharmaceutical claims from health professionals. This administration occurs under the Health Insurance BC (HIBC) program. Policy and decision-making functions remain the responsibility of the Ministry. HIBC submits monthly reports to the Ministry regarding performance on service levels to the public and health care providers. HIBC processes payments for health care services in accordance with payment schedules approved by the MSC.
HIBC is required to comply with all applicable laws, including the:
MSP premiums were eliminated January 1, 2020, prior to the reporting period. The MPA was amended pursuant to the Medicare Protection Amendment Act, 2019, to effect this change.
While premiums were eliminated prior to the reporting period, there may be collections actions still underway for outstanding debts owed for periods of MSP enrolment prior to the elimination of premiums. Prior to January 1, 2020, adult MSP beneficiaries who did not meet the (primarily income-based) exceptions were obligated to pay premiums. With respect to MSP premiums incurred prior to this time, the Receivables Management Office, Revenue Division (Ministry of Finance), performs revenue management services, including account management and collections. The Government of BC remains responsible for and retains control of all government administered collection actions.
The Hospital Act and Hospital Act Regulation provide authority for the Minister to designate facilities as hospitals and societies as hospital societies; license private long-term care hospitals (also referred to as long-term care homes); approve the bylaws of hospitals; inspect hospitals; and appoint a public administrator. This legislation also establishes broad parameters for the operation of hospitals.
The Hospital Insurance Act and the Hospital Insurance Act Regulations provide authority for the Minister to make payments to health authorities for the purpose of operating hospitals. They also outline who is entitled to receive publicly funded services and define the "general hospital services" that are to be provided as benefits.
Medically required hospital services are publicly funded benefits. There is no scheduled or regular process to review publicly funded hospital services, as these services are intended to be inclusive.
All hospital services that were funded in 2020-2021 continued to be funded in 2021-2022.
When medically required, the following are provided to beneficiaries who are in-patients in a general hospital:
When medically required, the following are provided as benefits to out-patients who are beneficiaries:
When medically required, the following diagnostic services—which are specified in the Medical and Health Care Services Regulation under the Medicare Protection Act (MPA)—are provided as benefits to out-patients who are beneficiaries. Depending on the service, they may be provided at hospitals or privately-owned facilities that the MSC has approved to provide the service, including:
Medically required in-patient and out-patient laboratory services are provided as benefits under the LSA.
Insured hospital services are provided to beneficiaries without charge, with a few exceptions, such as:
Some facilities providing long-term care services (the term "extended care" is also sometimes used) are regulated under Part 2 of the Hospital Act. Health authorities and hospital societies are required to follow Home and Community Care policies to determine benefits in such cases.
In accordance with the definition of "benefits" under the MPA, diagnostic services such as MRI and CT scans are insured benefits only if delivered in a facility approved by the Medical Services Commission; during 2021-2022, there have been no changes to the legislation or regulations to address patient payments for services in private (not approved) diagnostic facilities.
Unless specifically excluded, the following medical services are publicly funded as benefits under the MPA or the LSA:
To practice in BC, physicians must be registered and in good standing with the College of Physicians and Surgeons of BC. To receive payment for publicly funded services, they must be enrolled with MSP. In the fiscal year 2021-2022, 12,376, physicians were enrolled with MSP and received payments through fee-for-service (FFS).
The types of practitioners (in addition to physicians and dentists) who may enrol and provide benefits under MSP include midwives, optometrists, osteopaths and supplementary benefit practitioners (e.g., Chiropractors and Massage Therapists). Nurse practitioners are not included as they enrol to get a practitioner number but do not provide MSP benefits and are not listed as health care practitioners under the MPA. Additionally, Registered Nurses with certified practice (RN(C)) are authorized to independently refer eligible MSP beneficiaries for selected medically necessary laboratory tests approved as within scope of practice outlined by the British Columbia College of Nurses and Midwives. This program is of particular benefit to patients in communities who do not have an attendant physician or nurse practitioner, but who do have access to nursing care provided by an RN(C). RN(C)s do not submit billing information to MSP; they may only make referrals for approved laboratory services.
For eligible beneficiaries, the Supplementary Benefits Program provides partial payment for acupuncture, massage therapy, physiotherapy, chiropractic, naturopathy, and non-surgical podiatry services. The program contributes $23 towards the cost of each patient visit to a maximum of ten visits per patient per annum summed across the six types of providers. Eligibility for the program is based on income. Income is verified by way of an automated Canada Revenue Agency income verification process that runs once per year. Clients of the Ministry of Social Development and Poverty Reduction may be eligible to receive an additional twelve visits per year.
Practitioners enrolled in MSP may choose to be "opted-in" or "opted-out". Opted-in practitioners are those who are enrolled in MSP and who elect to bill MSP directly for MSP benefits provided to MSP beneficiaries. An opted-in practitioner may not bill a patient directly for an insured benefit. Opted-out practitioners are enrolled in MSP but elect to bill patients directly for benefits. Enrolled practitioners wishing to opt out of MSP must give written notice to the MSC. In this case, beneficiaries may apply to MSP for reimbursement of the fee for benefits rendered. Under the MPA, an opted-out physician may not charge a patient more for a benefit than the prescribed MSP fee amount.
Unenrolled physicians are not registered with MSP. Consequently, services provided by a physician who is not enrolled or whose enrolment has been cancelled with MSP are not insured and are not reimbursed by MSP. By law, unenrolled physicians in BC may not charge patients more than the MSP amount for an insured benefit that is provided at a hospital, or community care facility, or other setting set out in the MPA.
Under the Physician Master Agreement (PMA) between the Government of BC, MSC, and Doctors of BC, modifications to the MSC Payment Schedule such as additions, deletions, or fee changes are made by the MSC upon advice from Doctors of BC or the Government of BC.
During fiscal year 2021-2022, 31 net new types of services by physicians were added to the MSC Payment Schedule to reflect current practice standards including, for example, the introduction of three new Otolaryngology services for Telehealth (consultation, repeat or limited consultation, and subsequent office visits), and eleven new Pain Medicine services for percutaneous radiofrequency neurotomies.
Additionally, two types of physician services were deleted from the MSC Payment Schedule in fiscal 2021-2022: Obstetrics and Gynecology services for vulvar intraepithelial lesion (diffuse or multifocal), and removal of vaginal inclusion cyst. These services were deleted as they could be billed under other existing fee(s) and/or had been rarely performed as a stand-alone procedure.
Also, as part of the response to and planning for the COVID-19 pandemic, amendments to the MSC Payment Schedule were made in 2019-2020, 2020-2021 and 2021-2022 on a temporary basis to support access to physician services during the pandemic, including virtual care and immunizations. Temporary changes to the MSC Payment Schedule, including new fees, were implemented with the end dates of the temporary fees to be determined by the Provincial Health Officer.
Temporary fee changes include:
In certain circumstances, in-patient or out-patient hospitalization is medically required for the safe and proper completion of surgical-dental services. In such cases, the surgical-dental procedure component is publicly funded if the service falls within the meaning of covered dental or orthodontic services by the Medical and Health Care Services Regulation under the MPA. The hospitalization component is funded by the health authority. Further, dental services that are provided in privately owned/operated surgical facilities under contract with a health authority, and are listed in the Dental Payment Schedule, are insured benefits under MSP. During the 2020-2021 reporting period, the Medical and Health Care Services Regulation was amended to authorize payment for oral and maxillofacial surgical services in relation to a public health emergency.
Publicly funded surgical-dental procedures include those related to remedying a disorder of the oral cavity or a functional component of mastication. Generally, this includes oral surgery related to trauma, orthognathic surgery, medically required extractions, and surgical treatment of temporomandibular joint dysfunction.
The dental procedures funded by MSP are established through the negotiation of an agreement between the BC Dental Association (BCDA) and the Government of BC. Public consultation is not undertaken. The agreement outlines any changes to surgical-dental benefits during the term of the agreement, including any additional benefit procedures. Additions or changes to the list of benefits are managed by MSP on the advice of the Dentistry Advisory Committee, which consists of representatives from both the Ministry and the BCDA. Additions and changes to the Dental Payment Schedule must be approved by the Dentistry Special Committee (under the MPA). As agreed to in the 2019 master agreement between the BCDA and the Government, in October 2020, new fee items for cryotherapy and topical photodynamic therapy were added to the payment schedule, and were available to be billed during the reporting period. These were added to replace the former fee items for surgery with carbon dioxide laser. A new 2022 agreement is currently being negotiated.
Any general dentist in good standing with the College of Dental Surgeons of British Columbia who is enrolled in MSP and has hospital privileges may provide surgical-dental benefits in a hospital or other approved facility. There were 204 dentists enrolled with MSP in 2021-2022 (including general dentists, pediatric dental specialists, oral surgeons, oral medicine dental specialists, and orthodontists billing through MSP).
Dentists must register with the College of Dental Surgeons of British Columbia to practise, but they are not required to participate in MSP. If they choose to participate, they must enrol in MSP to receive payment for MSP insured services. Dentists enrolling in MSP may choose to opt out of billing MSP for insured services, instead billing the patient directly. The patient may then submit a claim to MSP for reimbursement of the insured service.
Medical necessity is the criterion for public funding of hospital and medical services. Coverage is excluded for out-patient take-home drugs, and any drugs not clinically approved by the hospital. Procedures not publicly funded under the Hospital Insurance Act and Hospital Insurance Act Regulations include:
Non-publicly funded hospital services also include:
Health authorities are required by Ministry policy to fund medically necessary transfers between acute care hospitals within BC, but beneficiaries (subject to an income-based exemption) are required to pay a fee to partially off-set costs when an ambulance or contracted alternative service provider is used for transport in other situations.
Services not covered under MSP include:
With respect to MSP, the MSC has authority to determine which services are not benefits.
Temporary hospital fee changes were made in response to COVID-19. To remove potential barriers to COVID-19 related health care in acute care hospitals during the COVID-19 health crisis, a temporary policy change in regard to insured hospital services and goods came into effect on May 21, 2020. The Temporary Amendment to Funding of Hospital Services Related to COVID-19 policy provides a fee suspension that impacts only hospital services and goods related to COVID-19 for individuals in BC who are not eligible for MSP coverage (e.g., people who have precarious immigration status), and it aligns with the MSP response to COVID-19 (http://www.gov.bc.ca/msp-covid). This temporary policy applies to all acute care hospitals in the province, and provides that:
Section 7 of the Medicare Protection Act (MPA) sets out the Medical Services Plan (MSP) requirement for residents of British Columbia to enroll in MSP. A person must be a resident of British Columbia (BC) to be eligible for provincial health care benefits.
Section 1 of the MPA defines a resident as a person who is either deemed to be a resident under regulation, or:
"Deemed residents" include individuals such as some holders of permits issued under the federal Immigration and Refugee Protection Act (see section 3.2 of this report) among others, but this does not include a tourist or visitor to BC.
Residents who do not want to participate in the BC's public health care plan may choose to opt out of the publicly funded program. Individuals are required to file an Election to opt out statement and submit that statement to the MSC. A statement, once signed, is irrevocable and results in the resident being responsible for paying the entire cost of all hospital, medical and other health care services they may receive during the 12-month opted-out period. Residents cannot opt out retroactively and must reapply to opt out at the expiry of each 12-month period.
All residents are entitled to medically required hospital and medical care coverage. Those residents who are members of the Canadian Armed Forces and those serving a term of imprisonment in a federal penitentiary, as defined in the Corrections and Conditional Release Act, are eligible for federally funded health insurance. MSP provides first-day coverage to discharged members of the Canadian Armed Forces and to those returning from an overseas tour of duty, as well as to released inmates of federal penitentiaries located in BC.
It is possible for a beneficiary's enrollment to be cancelled by order of the MSC, if the MSC determines that the beneficiary was not eligible for enrollment or the beneficiary has ceased to be a resident. Section 11 of the MPA requires that the beneficiary must be notified that they have a right to a hearing, prior to making an order cancelling a beneficiary's enrollment. If the beneficiary requests a hearing, the hearing is conducted by a delegate of the Medical Services Commission (MSC) — either in person or in writing. Decisions of the MSC or its delegates may be judicially reviewed by the Supreme Court of BC.
The number of residents registered with MSP, as of the end of the reporting period on March 31, 2022, was 5,328,995.
Holders of study permits and work permits, applicants for permanent resident status who are the spouse or child of an eligible resident, and individuals who have arrived in BC under the Canada-Ukraine authorization for Emergency Travel are eligible for enrolment and benefits when they are deemed to be residents under the MPA in accordance with section 2 of the Medical and Health Care Services Regulation.
Until January 1, 2020, the MPA and the Medical and Health Care Services Regulation provided authority for the MSC to collect premiums from beneficiaries. As announced by the Government of BC, and further to amendments enacted through the Medicare Protection Amendment Act, 2019, MSP premiums were eliminated for all beneficiaries effective January 1, 2020.
Retroactive premium assistance for premiums incurred prior to January 1, 2020, remains available.
Effective July 2, 2013, Health Canada transferred the funds historically used to pay MSP premiums on behalf of status First Nations residents in BC to the First Nations Health Authority (FNHA). Of this transfer, 25 per cent over the first three years was set aside by FNHA to support the development of new primary care services. The 2013 Agreement Regarding Payments in Lieu of MSP Premiums on behalf of First Nations people resident in the province of BC was successfully renegotiated in 2018, and although the Government of BC eliminated MSP premiums for British Columbians effective January 1, 2020, FNHA continues to receive annual funding from the Ministry to support these primary care services through a joint Ministry of Health-First Nations Health Authority project/priorities board.
As the province has eliminated MSP premiums for British Columbians, an updated payment method helps to ensure international students continue to contribute to, and benefit from, BC health care coverage. Under the updated system, effective September 1, 2019, all international K-12 and post-secondary students began paying a monthly health care coverage fee of $37.50.
For post-secondary students who were paying $37.50 per month in MSP premiums, the health fee restored their contributions to the $75 per month that was charged prior to 2018. Effective January 1, 2020, the health fee for international students is $75 per month.
International students with a study permit valid for a period of six or more months are required to apply for MSP as soon as they arrive in BC. Through this application process, they will be enrolled and then invoiced for the new health fee following the mandatory coverage wait period. Any outstanding International Student Health Fee debt is not a barrier to receiving coverage.
New residents or persons re-establishing residence in British Columbia (BC) are eligible for coverage after completing a waiting period that normally consists of the balance of the month in which residence is established, plus two additional months. For example, if an eligible person applies 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 provincial or territorial health insurance plan during the waiting period.
Sections 3, 3.1, 4, and 5 of the Medical and Health Care Services Regulation set out the portability provisions for persons temporarily absent from British Columbia regarding publicly funded services.
In general terms, residents who spend part of every year outside BC must be physically present in BC at least six months in a calendar year, and continue to maintain their home in BC, to retain coverage. However, longer term vacationers who are deemed residents may qualify for a total absence of up to seven months per calendar year for vacation purposes only, provided they give prior notice to the Medical Services Commission (MSC) and continue to meet the other requirements, such as maintaining their home in BC.
Individuals leaving BC temporarily on extended vacations, or for temporary employment, may be eligible to retain their medical coverage for up to 24 consecutive months provided they receive prior approval of the MSC and meet other requirements of section 4 of the Medical and Health Care Services Regulation. Approval is limited to once in five years for absences exceeding six months in a calendar year. When a beneficiary stays outside BC longer than the approved period, there is a requirement to fulfill a waiting period upon re-establishing residence in the province before coverage can be renewed. Students and extended family of students attending a recognized school in another province or territory on a full-time basis are entitled to coverage for the duration of their studies.
According to inter-provincial/territorial reciprocal billing arrangements, physicians in other Canadian provinces and territories, except in Quebec, bill their own medical plans directly for services rendered to BC residents who are eligible for Medical Services Plan (MSP) coverage, upon presentation of a valid Personal Health Number or BC Services Card. BC 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 inter-provincial/territorial reciprocal billing rate. Payment for these services, except for excluded services that are billed to the patient, is handled through inter-provincial/territorial reciprocal billing procedures.
Quebec does not participate in reciprocal billing agreements for physician services. As a result, claims for services provided to BC beneficiaries by Quebec physicians are 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 the Government of BC.
BC pays host provinces/territories the approved hospital billing rates and out-patient rates. These rates are recommended by the Interprovincial Health Insurance Agreements Coordinating Committee and approved by provincial-territorial Deputy Ministers of Health.
The provisions that set out the portability of health insurance during temporary absences outside Canada are as follows: section 24 of the Hospital Insurance Act; Division 6 of the Hospital Insurance Act Regulations; sections 5.5 and 29 of the Medicare Protection Act (MPA); and sections 3–5 and 35 of the Medical and Health Care Services Regulation.
Residents who leave BC temporarily to attend school or university are eligible for MSP coverage for the duration of their studies, provided they were physically present in Canada for six of the 12 months immediately preceding departure and are in full-time attendance at a recognized educational facility. Beneficiaries who have been studying outside BC must return to the province by the end of the month following the month in which studies are completed. Any student who will not return to BC within that timeframe is encouraged to contact MSP.
In some circumstances, while temporarily outside the province for work or vacation, an individual may be deemed an eligible resident during an ’extended absence’ of up to 24 consecutive months, once in a five-year period. To qualify, an individual must obtain prior approval for status as a resident during the absence, continue to maintain their home in BC, be physically present in Canada for six of the 12 months immediately preceding departure, and have not been granted an extended absence in the previous five calendar years. In addition, they must not have taken advantage of the additional one-month absence available to vacationers during the year the extended absence begins, or during the calendar year prior to the start of the extended absence. In certain situations, if a person's employment requires them to routinely travel outside of BC for more than six months per calendar year, they can apply to the MSC for approval to maintain their eligibility.
BC residents who are temporarily absent from BC and cannot return due to extenuating health circumstances may be deemed residents for up to an additional 12 months. This also applies to the person's spouse and children provided they are with the person, and they are also residents or deemed residents.
BC residents who are eligible for coverage while temporarily absent from BC may receive reimbursement from MSP for out-of-country medical expenses. Provincial coverage for emergency medical treatment applies to a BC resident who unexpectedly requires medical care while travelling (business, pleasure, study) in another country. MSP provides coverage for out-of-country emergency physician services up to the BC physician fee rates. Reimbursement for out-of-country emergency hospital services is limited to a maximum benefit of $75 per day. Any excess cost is the responsibility of the beneficiary.
Reimbursements are made in Canadian dollars.
No prior approval is required for medically required procedures that are covered under interprovincial reciprocal agreements with other provinces and territories. Prior approval from the MSC is required for procedures that are excluded under the reciprocal agreements.
The physician services excluded under the Interprovincial Agreements for the Reciprocal Processing of Out-of-Province Medical Claims are:
All elective (non-emergency) procedures performed outside Canada require approval from the MSC before the procedure is performed, to be eligible for coverage under the publicly funded program. All such applications for provincial coverage are to be submitted to the Ministry or its designate, HIBC. The beneficiary is notified of the decision in writing.
If a decision is made to deny the application for funding, the beneficiary may request an administrative review of the denial.
If, after the administrative review is concluded, the application for funding under MSP is denied again, the beneficiary may request a review of the decision. For out-of-country applications, the review is conducted by an MSC Review Panel. The panel consists of three members—one delegate representing the Ministry, one delegate representing the Doctors of BC, and one delegate representing the general public. This tripartite structure ensures that decisions affecting administration of the provincial health care system reflect the best interest of all concerned.
For out-of-province but inside Canada applications, the review is conducted by an advisory committee of the MSC.
The Medical Services Commission (MSC) has a legislative mandate to protect the integrity and sustainability of the health care system and uphold the Medicare Protection Act (MPA). Section 36 of the MPA gives the MSC the authority to audit private clinics for extra-billing. Extra-billing is the practice of charging beneficiaries for the Medical Services Plan (MSP) benefits, or for matters relating to the rendering of benefits.
On October 1, 2018, the Government of British Columbia (BC) brought sections of the MPA that had previously been passed by the Legislative Assembly in 2003 (Bill 92) into force. In general terms, these provisions enhance enforcement powers in relation to extra-billing to better ensure that eligible BC residents (beneficiaries) receive quality public health care based on need, not on ability to pay. These changes uphold the fundamental principles of the MPA, as well as the Canada Health Act.
Several of the new MPA provisions were subject to a series of injunctions of varying scope, as part of the Cambie Surgeries Corp. v. British Columbia (Attorney General) litigation in which the plaintiffs challenged the extra-billing provisions contained in the MPA. In September 2020, the injunction expired when the British Columbia Supreme Court issued its decision in that litigation (dismissing the plaintiffs’ claims challenging the MPA). In December 2020, a new limited form of injunction was granted until June 18, 2021, and subsequently extended to September 30, 2021, or further order of the court (this injunction has expired). Subsequent to the current reporting period, on July 15, 2022, the BC Court of Appeal upheld the BC Supreme Court decision. As of September 29, 2022, the plaintiffs have applied for leave to appeal to the Supreme Court of Canada.
The MPA (section 45) prohibits the sale or issuance of health insurance by private insurers to patients for services that would be a publicly funded benefit. Section 17 prevents extra-billing by prohibiting persons from being charged for, or in relation to, a benefit or for "materials, consultations, procedures, use of an office, clinic or other place or for any other matters that relate to the rendering of a benefit" provided by a practitioner who is enrolled in MSP (and not opted-out).
In 2018, the MPA was amended to strengthen requirements for beneficiaries to be notified of intended charges for services that would be benefits if rendered by a practitioner who is enrolled in MSP. If notice is not provided as required, a person is not liable to pay for the service unless the service was rendered in an emergency, making it impracticable to comply with the notice requirement.
Beneficiaries, as defined in section 1 of the MPA, are eligible for medically required publicly funded health care services. To ensure equal access to all regardless of income, sections 17 and 18 of the MPA limit charges by medical practitioners in most contexts. Similarly, section 15 of the LSA prohibits extra-billing to beneficiaries for medically required laboratory services provided at an approved laboratory facility, and sections 12 and 13 of the Hospital Insurance Act prohibit extra-billing for hospital services.
If a benefit is provided by an enrolled medical practitioner who has opted out of MSP, any amount charged which exceeds the amount allowed under the MPA is considered extra-billing and must be refunded. The MSC may apply for an injunction restraining a person from contravening the extra-billing provisions of the MPA.
The Audit and Inspection Committee (AIC) is a four-member panel of the MSC comprised of three physicians (one of whom represents government) together with one member who represents the public. The MSC has delegated its powers and duties under section 36 of the MPA (i.e., to audit and inspect medical practitioners) to the AIC. On December 1, 2006, section 10 of the Medicare Protection Amendment Act, 2003 was brought into force. This section expanded the audit and inspection powers of the Commission to include the power to audit clinics as corporate entities, rather than just physicians.
The AIC has responsibility for two types of audits: (1) patterns of practice audits are done to ensure that services billed to MSP have been delivered and billed accurately; and (2) extra-billing audits focus on whether beneficiaries are being charged for services in contravention of the MPA. The AIC decides whether on-site audits are appropriate, and it outlines the nature and extent of the audits. It also reviews the audit results and makes recommendations to the Chair of the MSC for further appropriate action.
The Billing Integrity Program develops and analyses practitioner's profiles, monitors trends, conducts audits. Where appropriate, the MSC seeks recovery of inappropriately paid monies in accordance with the MPA.
A hearing is held before a panel of three or more persons who are appointed by the MSC to represent the Doctors of BC, beneficiaries, and government. A panel has authority to make an order for recovery of money and other remedies. The hearing affords the practitioner a fair process that adheres to the rules of natural justice.
If a beneficiary believes they have been charged inappropriately for an insured medical benefit, they can request a review by completing an extra-billing investigation form. This form is available publicly on the MSP website.
The MSC's audit powers over health care practitioners have been assigned to various special committees. A special committee for each body of health care practitioners has been established. The special committees are: the Chiropractic Special Committee; the Dentistry Special Committee; the Massage Therapy Special Committee; the Naturopathy Special Committee; the Optometry Special Committee; the Physical Therapy Special Committee; the Podiatry Special Committee; the Acupuncture Special Committee; and the Midwifery Special Committee.
Each audit results in the submission of a detailed report to the individual Special Committee. Subsequently, the individual Special Committee makes recommendation to the Health Care Practitioners Special Committee for Audit Hearings to assist in determining if recovery should be pursued. Practitioners have a right to be heard before the Health Care Practitioners Special Committee for Audit Hearings makes a determination.
Further, access to publicly funded services continues to be enhanced. The Ministry's focus is on increasing access to team-based quality, comprehensive, culturally safe, and person-and-family-centered primary care services for people across BC. Through this focus, the Ministry's primary care strategy will increase the collaborative participation of health care providers and organizations in the provision of primary care services. To support team-based care, the Ministry has implemented or expanded alternate compensation options, in addition to other existing compensation models:
Infrastructure and Capital Planning
BC continues to make strategic investments in health sector capital infrastructure. The Ministry invests annually to renew and extend the asset life of existing health facilities, medical and diagnostic equipment, and information management technology at numerous health facilities across BC. The Ministry maintains a long-term capital plan to ensure health infrastructure is maintained and renewed within expected asset lifecycle timelines.
The PMA is a formal agreement signed by the Government of BC, the Doctors of BC, and the MSC. The agreement supports ongoing efforts to recruit and retain physicians, while also improving access to FPs, specialists, and health care in rural and remote communities. The three-year agreement expired on March 31, 2022, and a new agreement was under negotiation at the end of the reporting period.
The Doctors of BC represent the interests of all physicians who receive payment for the medical services they provide to beneficiaries in relation to the PMA. The PMA establishes mechanisms that promote enhanced collaboration and accountabilities between the Government of BC and Doctors of BC through various joint committees. It also provides a formal conflict management process at both the local and provincial levels, and language limiting physician service withdrawals. The role of health authorities in the planning and delivery of health care services is reinforced in the PMA.
Under the authority of the MPA, the PMA establishes the compensation and benefit structure for physicians who provide publicly funded medical services whether via FFS, contract, or blended capitation funding models. Through the PMA, the Government of BC also provides targeted financial support for areas such as: rural programs; specialist services; full-service family practice; and shared care models involving FPs, specialists, and other health care professionals.
Physicians are registered by the College of Physicians and Surgeons of BC, a body established under the Health Professions Act. The PMA provides processes for monitoring and managing the funding established by the MSC under section 25 of the MPA for publicly funded medical services provided by physicians on a FFS basis. Mechanisms for revisions to the MSC Payment Schedule and for the payment of physicians are detailed in the PMA.
Dentists are registered by the College of Dental Surgeons of BC, which is also a body established under the Health Professions Act. The Dentistry Master Agreement between the Province and the BCDA covers the following services: dental surgery; oral surgery; orthodontic services; oral medicine; pediatric dental services; and dental technical procedures. The Province and the BCDA collaborate through a Dentistry Liaison Committee. The current three-year agreement expired March 31, 2022, and a new agreement was under negotiation at the end of the reporting period.
Payment for medical services delivered in BC is made through MSP to the following: individual practitioners who submit claims under FFS; health authorities who contract and employ physicians for providing services to patients; and health authorities and/or physician groups who provide patient services under blended capitation funding models.
The MSC is authorized to monitor the billing and payment of claims in order to manage expenditures for medical and health care benefits on behalf of MSP beneficiaries. The Ministry's Billing Integrity Program monitors, audits and investigates billing patterns and practices of medical and health care practitioners to detect and deter inappropriate and incorrect billing of MSP claims to MSC. The Billing Integrity Program develops and analyzes practitioners’ profiles, monitors trends, and conducts audits for the MSC. Further, where appropriate, the MSC seeks recovery of inappropriately paid monies in accordance with the MPA.
Funding for publicly funded hospital services is included within annual funding allocations to health authorities, as well as specifically targeted funding from time to time. This funding allocation is used to fund the full range of necessary health services for the population of the region (or for specific provincial services, for the population of BC), including the provision of hospital services. Annual funding allocations to health authorities are determined as part of the Ministry's annual budget process in consultation with the Ministry of Finance and Treasury Board. The current year funding allocations and notional out-year allocations are conveyed to health authorities by means of annual funding letters.
The Hospital Insurance Act (including the Hospital Insurance Act Regulations) and the Health Authorities Act govern payments made by the Government of BC to health authorities. These statutes establish the authority of the Minister to make payments to regional health authorities and PHSA and specify in broad terms what services are publicly funded when provided within a hospital and in delivering regional and other health care services.
The BC Tripartite Framework Agreement on First Nation Health Governance and other negotiated agreements provide the basis for the Ministry to provide funding to the FNHA. Funding to support the Nisga’a Nation health care services and programs is provided to the Nisga’a Valley Health Authority under the terms of the 1999 Nisga’a Valley Health Board Transitional Funding Agreement.
The Ministry does not specifically fund hospitals directly; instead, health authorities are funded and provide operating budgets to hospitals within their regions to deliver specified services. The exception to this is when funding provided to health authorities (again not directly to hospitals) is targeted for specific priority projects (e.g., to fund wages or to provide operating funding to support large hospital construction projects coming on stream). Since it is specifically targeted, the funding must be reported on separately.
Annual incremental funding is allocated to health authorities using the Ministry's Population Needs-Based Funding model and other funding allocation methodologies (targeted funding allocations directed to specific health authorities, e.g., for wage costs related to collective bargaining). The annual funding allocation to health authorities does not include funding for programs directly operated by the Ministry, such as payments to physicians that occur through MSP and payments for prescription drugs that are covered under PharmaCare.
The accountability mechanisms associated with government funding for hospitals are part of several comprehensive documents that set expectations for health authorities. These include the annual funding letters, annual service plans, mandate letters, and annual bilateral agreements. 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.
Funding provided by the federal government through the Canada Health Transfer is recognized and reported by the Government of British Columbia (BC) through various government websites and provincial government documents. In 2021–2022, these documents included:
As per the guidelines, the number of public facilities in this table excludes psychiatric hospitals and extended care facilities.
Return to footnote 1 referrer
BC Ministry of Health Funding to Health Authorities for the provision of the full range of regionally delivered services are as follows: $12.1 billion in 2017-2018, $12.7 billion in 2018-2019, $13.7 billion in 2019-2020, $14.6 billion in 2020-2021 and $15.6 billion in 2021-2022.
Return to footnote 2 referrer
Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
Return to footnote 3 referrer
The number of participating physicians in item 18 is for physicians who received payments through fee-for-service.
Return to footnote 4 referrer
Health Canada requested this data as of the 2019-2020 report, but did not require provinces or territories to report data for 2015-2016.
Return to footnote 5 referrer
The Government of Yukon is committed to ensuring that Yukoners acquire the skills to live responsible, healthy, and independent lives. The Department of Health and Social Services (HSS) and its Minister are responsible for delivering all insured health care services.
In 2021-2022, HSS primarily focused on implementing the recommendations outlined in the Putting People First report, which was created by an Independent Expert Panel following a comprehensive review on health and social services in the Yukon. Part of this work included the introduction of funded and regulated midwifery services; updating medical travel subsidy rates; and increasing the use of virtual care for Yukoners to connect with care providers from their homes and in their communities.
The Yukon has not experienced a COVID-19 backlog; however, often relies on out-of-territory counterparts to meet the needs of Yukoners. Due to backlogs in other jurisdictions, Yukoners have experienced longer waits to access services in neighbouring provinces.
Insured Health Services (IHS) delivers health care benefits as set out in the Health Care Insurance Plan Act and Hospital Insurance Services Act. The objective of IHS is to ensure access to insured physician and hospital services in line with these Acts.
The Government of Yukon delivers insured health benefits according to the Yukon Health Care Insurance Plan (YHCIP) and the Yukon Hospital Insurance Services Plan (YHISP). Both the YHCIP and YHISP are administered by the Director of IHS (the Director). This position is a joint appointment by the Minister and the Commissioner of the Yukon Territory.
The Health Care Insurance Plan Act, section 3(2) and section 4, establishes the public authority to operate the health care plan. The Hospital Insurance Services Act, section 3(1) and section 5, establishes the public authority to operate the hospital care plan.
Subject to the Health Care Insurance Plan Act (section 5), the Hospital Insurance Services Act (section 6), and the Regulations, it is the responsibility of the Director to do the following:
Specific to the Hospital Insurance Services Act, the Director has the responsibility to:
There were no amendments to either Act in 2021-2022; however, the Midwives Regulation was introduced under the Health Professions Act during this period.
The Midwifery Regulation came into force in April 2021. With the introduction of midwifery care, births can now take place in a home anywhere in the Yukon, or a hospital setting outside of Whitehorse, as appropriate. Registered midwives work with community health care providers to provide midwifery supported pre- and post-natal to Yukoners. The midwifery program is government led, with registered midwives employed by the Government of Yukon.
HSS 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 submit an annual report on the administration of the two health insurance plans to the Minister. This report, "A Statement of Revenue and Expenditures", is tabled and reviewed in the legislature. The latest version of this report was tabled in the 2021 fall sitting of the Yukon legislature.
YHCIP and YHISP are subject to audit by the Office of the Auditor General of Canada. The Auditor General of Canada is the auditor of the Government of Yukon in accordance with section 34 of the Yukon Act. 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 must report to the Yukon Legislative Assembly any matter falling within the scope of the audit that should be reported to the Assembly.
Further, section 13(2) of the Hospital Act requires the Yukon Hospital Corporation to submit a report of their operations for that fiscal year to the Minister within six months after the end of each fiscal year. The report is to include the financial statements of the Corporation and the Auditor's report.
The Hospital Insurance Services Act, sections 3, 4, 5, 6, and 9, establish authority to provide insured hospital services to insured residents. The Yukon Hospital Insurance Services Ordinance was first passed in 1960 and came into effect April 9, 1960. No amendments were made to the Act in 2021-2022.
Adopted on December 7, 1989, the Hospital Act establishes the responsibility of the legislature and the government to ensure "compliance with appropriate methods of operation and standards of facilities and care." Adopted on November 11, 1994, the annexed Hospital Standards Regulation sets out the conditions under which all hospitals in the territory are to operate. Section 4(1) provides for the Ministerial appointment of one or more investigators to report on the management and administration of a hospital. Section 4(2) requires that the hospital's Board of Trustees establish and maintain a quality assurance program.
In April 1997, the Yukon government assumed responsibility for operating health units in rural Yukon communities from the federal government. These health centres are staffed by one or more nurses and auxiliary staff. In the absence of a physician, primary health care nurses provide daily clinics for medical treatment, community health programs, and 24-hour emergency services in 11 communities throughout the Yukon along with the Whitehorse Health Centre, which offers immunization clinics and pre/postnatal care.
In March 2020, a respiratory assessment centre was opened in Whitehorse to assess patients with respiratory illnesses and test for COVID-19. The centre closed in 2021-2022.
In 2021-2022, insured in-patient and out-patient hospital services were delivered in Whitehorse General Hospital, Watson Lake Community Hospital, Dawson City Community Hospital. 11 community health centres across the Yukon provide out-patient hospital services.
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:
Section 2(f) of the Hospital Insurance Services Regulations defines "out-patient insured services" as all of the following services to out-patients, when used for emergency diagnosis or treatment within 24 hours of an accident (period may be extended by the Administrator, provided the service could not be obtained within 24 hours of the accident):
All diagnostic services available in the Yukon are provided through the hospitals, including magnetic resonance imaging (MRI) and computerized tomography (CT) scans. There are currently no private clinics providing diagnostic services. For services that are not available in the Yukon, patients receive care out-of-territory, usually in British Columbia or Alberta.
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. This process is managed by the Director of Insured Health Services. Public representation regarding changes in service levels is made through membership on the hospital board.
Insured physician services in the Yukon are defined as medically required services rendered by a medical practitioner. Sections 1 to 8 of the Health Care Insurance Plan Act and sections 2, 3, 7, 10, and 13 of the Health Care Insurance Plan Regulations provide for insured physician services. No amendments were made to either Act in 2021-2022.
The Yukon Health Care Insurance Plan (YHCIP) covers physicians providing medically required services. Physicians cannot opt out of YHCIP and must do the following:
There were 93 physicians participating in YHCIP in 2021-2022. These physicians were supplemented by visiting locum physicians who provide care throughout the Yukon. In 2021-2022, there were no physicians practicing in the territory who were providing services outside of YHCIP.
Section 7 of the Yukon Health Care Insurance Plan Regulations covers payment for medical services. Subsection 4 allows physicians to arrange for payment for insured services on a basis other than fee-for-service. If a physician chooses to do this, they must submit notice in writing to the Director. In 2021–2022, physicians received payment through both fee-for-service and alternative arrangements.
The process of adding a new fee to the Payment Schedule for the Yukon is administered through a committee structure. This process requires physicians to submit requests in writing to YHCIP and the Yukon Medical Association Fee Liaison Committee. After review, the committee decides whether to include service. The fees are normally set in accordance with similar fees in other jurisdictions. Once a fee-for-service value has been determined, Yukon physicians are notified of the service and the applicable fee. Public consultation is not required.
New fees can also be implemented through fee negotiation between the Yukon Medical Association and the Department of Health and Social Services.
The newest Memorandum of Understanding (MOU) with the Yukon Medical Association was ratified October 5, 2022, and reflects the values of new culture; seamless transitions; access and attachment to primary care; and access and equity.
Dentists providing insured surgical-dental services under YHCIP must be licensed pursuant to the Dental Professions Act and bill YHCIP. Dentists providing services to Yukoners outside the territory also bill YHCIP directly.
Insured dental services are limited to surgical-dental procedures listed in Schedule B of the Health Care Insurance Plan Regulations. The procedures must be performed in a hospital. In 2021-2022, no dentists provided insured surgical-dental services under YHCIP.
Changes to the list of insured services requires public consultation and amendment by Order-in-Council to Schedule B of the Health Care Insurance Plan Regulations. Coverage decisions are made on the basis of whether or not the service must be provided in hospital under general anaesthesia. The Director administers this process.
There were no new insured surgical-dental services added in 2021-2022.
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:
Section 3 of the Yukon Health Care Insurance Plan Regulations contains a list of services that are prescribed as non-insured. Uninsured physician services include:
Yukon physicians may bill patients directly for non-insured services. Block fees are not used at this time; however, some physicians bill by service item. Billable services include but are not limited to:
Payment does not affect patient access to services because not all physicians or clinics bill for these services and other agencies or employers may cover the cost.
Uninsured dental services include procedures considered restorative and procedures that are not performed in a hospital under general anaesthesia.
All Yukon residents have equal access to services. Third parties, such as private insurers or the Worker's Safety and Compensation Board, do not receive priority access to services through additional payment. Purchasing non-insured services, like fiberglass casts, does not delay access to insured services. Insured persons are given treatment options at the time of service.
The Yukon has no formal process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals, and staff allows the Director to monitor concerns.
The process used to de-insure services covered by YHCIP is as follows:
Eligibility requirements for insured health services are set out in the Health Care Insurance Plan Act and Regulations, sections 2 and 4, and the Hospital Insurance Services Act and Regulations, sections 2 and 4. There were no changes to the legislation in 2021-2022.
Every Yukon resident is eligible for and entitled to insured health services on uniform terms. "Resident" is defined according to the Canada Health Act and means a person lawfully entitled to be or to remain in Canada, who makes their home and is ordinarily present in the Yukon, but does not include a tourist, transient, foreign student, or visitor. Pursuant to section 4(1) of the Yukon Health Care Insurance Plan Regulations and the Yukon Hospital Insurance Services Regulations, an insured person is eligible for insured services after midnight on the last day of the second month following the month of arrival to the Yukon. All persons returning to or establishing residency in the Yukon are required to complete this waiting period. The only exception is for newborns and children adopted by insured persons and members of the Canadian Armed Forces and their families.
The following persons are not eligible for coverage in the Yukon:
The ineligible persons noted previously may become eligible for coverage if they meet one or more of the following conditions:
As of March 31, 2022, there were 44,301 people registered in The Yukon Health Care Insurance Plan (YHCIP).
YHCIP also covers the following groups:
International students, temporary workers, tourists, transients, or visitors to the Yukon do not qualify as residents of the territory and are not eligible for YHCIP coverage.
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 the Health Care Insurance Plan Act and the Hospital Insurance Services Act 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 (see section 3.1 for exceptions).
The provisions relating to portability of health care insurance during temporary absences outside the 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. There were no changes to these regulations in 2021-2022.
The Regulations state that, "where an insured person is absent from the Territory and intends to return, he/she is entitled to insured services during a period of 12 months of continuous absence." Persons leaving the Yukon for more than six months must contact Yukon Insured Health Services and complete a Temporary Absence form. Failure to do so may result in cancellation of coverage.
Students attending schools full-time outside the Yukon remain eligible for the duration of their studies. The Director of Insured Health Services (the Director) may approve absences in excess of 12 consecutive months upon receiving a written request from the insured person. Requests for extensions must be renewed yearly and are subject to approval by the Director.
For temporary workers and missionaries, the Director may approve absences in excess of 12 consecutive months upon receiving a written request from the insured person. Requests for extensions must be renewed yearly and are subject to approval by the Director.
The provisions regarding coverage during temporary absences in Canada fully comply with the terms and conditions of the Interprovincial Agreement on Eligibility and Portability effective February 1, 2001. Definitions are consistent in regulations, policies, and procedures.
The Yukon participates fully with the Interprovincial Medical Reciprocal Billing Agreements and Hospital Reciprocal Billing Agreements in place with all other provinces and territories with the exception of Quebec. Persons receiving physician services in Quebec may be required to pay directly and submit claims to YHCIP 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 the 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 the Yukon, but within Canada.
Insured services provided to Yukon residents while temporarily absent from the territory are paid at the rates established by the host province.
The provisions 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. There were no changes to these regulations in 2021-2022.
Sections 5 and 6 state that, where an insured person is absent from the Yukon and intends to return, the person is entitled to insured services during a period of 12 months of continuous absence.
Persons leaving the Yukon for more than six months must contact YHCIP 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 the Yukon. Reimbursement is made to the insured person by YHCIP 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. For 2021-2022 the in-patient rate was set at $2,011 per day at Whitehorse General Hospital, $4,792 per day at Watson Lake Community Hospital and $5,899 per day at Dawson City Community Hospital. These rates are set annually by the Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC).
Insured out-patient hospital services provided to eligible Yukon residents outside Canada are paid at the rate established by the IHIACC.
There is no legislated requirement that eligible residents must receive approval before seeking elective or emergency hospital or physician services outside the Yukon or Canada.
When treatment is provided outside the Yukon or Canada, plan members will only be reimbursed the amounts as described in Sections 4.2 and 4.3.
Prior approval by the Director is required for full reimbursement of services sought outside of Canada.
There are no user fees under the Yukon Health Care Insurance Plan (YHCIP). All services are provided on a uniform basis and access is not impeded by financial or other barriers. There is no extra-billing in the Yukon for any services covered by YHCIP.
In 2021-2022, the Yukon did not have any private for-profit health care facilities delivering insured health services.
If a patient has a complaint related to physician services, including extra-billing or user charges, they can contact the Yukon Medical Council (YMC).
Information on complaints can be found on the YMC's website.
The YMC can be reached by phone at 867-667-3774 or by email to [email protected].
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 reduce delay in receiving necessary services.
To improve access to insured health services, the number of resident specialists working in the Yukon continues to increase to better serve Yukoners.
Additionally, Insured Health Services provides extended health benefits to eligible Yukon residents which include the Travel for Medical Treatment Program, the Children's Drug and Optical Program, the Chronic Disease and Disability Benefits Program, Pharmacare Program, Extended Benefits Program, and Hearing Services Program.
The Yukon Hospital Corporation operates the three hospitals in the territory: Whitehorse General Hospital, Watson Lake Community Hospital, and Dawson City Community Hospital.
The Department of Health and Social Services (HSS) 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. HSS seeks ratification of the agreement from the Government of Yukon. The final agreement is signed with the concurrence of both parties.
Payments to physicians and dentists for insured services are governed by the Health Care Insurance Plan Act and the Health Care Insurance Plan Regulations.
The fee-for-service system is used to reimburse the majority of physicians providing insured services. Other systems of reimbursement include alternative payment arrangements, which are primarily used for specialist services in Whitehorse as well as physician services in rural communities.
The Government of Yukon funds the Yukon Hospital Corporation (Whitehorse General Hospital, Watson Lake Community Hospital, and Dawson City Community Hospital) through 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. In addition to the established O&M and capital funding set out in the agreement, the hospital can submit requests for additional program funding.
Payments made by the health care plan to facilities that provide insured hospital services are governed by the Hospital Insurance Services Plan Act and Regulations. These legislation and regulations organize payments to hospitals for insured services provided to insured persons.
The Government of Yukon has acknowledged the federal contributions provided through the Canada Health Transfer in its 2021–2022 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.
Public facilities are the 11 health centres (Beaver Creek, Carcross, Carmacks, Destruction Bay, Faro, Haines Junction, Mayo, Old Crow, Pelly Crossing, Ross River, and Teslin) and 3 hospitals (Whitehorse, Dawson City and Watson Lake). As Whitehorse, Dawson City and Watson Lake all have hospitals, the health centres in these communities are classified as a Public Health Offices.
Return to footnote 1 referrer
Hospitals have up to a year from date of service to bill jurisdictions (information is based upon date of service; therefore, 2021-2022 billing period is open until March 31, 2023.
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Yukon does not have an electronic method of capturing pre-approved claims versus non pre-approved claims.Totals are reported as non pre-approved claims.
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Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
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Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report,but did not require provinces or territories to report on previous years.
Return to footnote 5 referrer
No insured surgical-dental services performed in Yukon.
Return to footnote 6 referrer
The Department of Health and Social Services (the Department) is responsible for setting the strategic direction for the health and social services system through the development of legislation, policy, and standards; establishing approved programs and services; establishing and monitoring system budgets and expenditures; and evaluating and reporting on system outcomes and performance measures. The Department is responsible for ensuring that all statutory functions and requirements are fulfilled, ensuring professionals are appropriately licensed and managing access to health insurance.
The Health and Social Services Authorities are governed by the Northwest Territories Health and Social Services Leadership Council (Leadership Council). Regional Wellness Councils provide advice to the Leadership Council and valuable information on the needs and priorities of the residents in their respective regions. The Leadership Council is responsible to the Minister of Health and Social Services (the Minister) for governing, managing, and providing health and social services in accordance with the plan set out by the Minister.
The Department recognizes that the identification of priorities and the development and delivery of responsive programs and services are best managed in partnership with Indigenous people and communities through an integrated system.
The Northwest Territories (NWT) Health Care Plan consists of the NWT Medical Care Plan and the NWT Hospital Insurance Plan.
The public authority responsible for the administration of the NWT Medical Care Plan is the Director of Medical Insurance, appointed by the Minister of Health and Social Services (the Minister), under s.23(1) of the Medical Care Act. The Minister establishes the Northwest Territories Health and Social Services Authority and the Health and Social Service Authorities' Boards of Management pursuant to s.5(1), s.10(1), and s.10(2) of the Hospital Insurance and Health and Social Services Administration Act. The Hospital Insurance and Health and Social Services Administration Act recognizes, at s.10.3(1), that the Tłı̨chǫ Community Services Agency established by the Tłı̨chǫ Community Services Agency Act is deemed to be a Board of Management. The territorial authority and the boards of management administer the Hospital Insurance Plan; their legislated mandate is to:
There were no amendments made in 2021-2022 to the Medical Care Act or the Hospital Insurance and Health and Social Services Administration Act.
During the reporting period there were three Health and Social Service Authorities: Northwest Territories Health and Social Services Authority (Territorial Authority), Hay River Health and Social Services Authority, and Tłı̨chǫ Community Services Agency.
Territorial Authority affairs are directed by a Territorial Board of Management, the Leadership Council. Six Regional Wellness Councils provide advice to the Leadership Council, which is composed of the Regional Wellness Council chairpersons and the chairperson of the Tłı̨chǫ Community Services Agency and the Deputy Minister of the Department. The Leadership Council is accountable to the Minister.
The Health and Social Services Authorities are responsible for the delivery of health and social services and for the management, control, and operation of facilities and services throughout the Northwest Territories. The Health and Social Services Authorities are required under legislation to comply with the territorial plan, which is set by the Minister.
The Minister appoints the Director of Medical Insurance who is responsible for administering the Medical Care Act and its Regulations. The Director prepares an annual report for the Minister on the operation of the NWT Medical Care Plan. This report can be found within the NWT Health and Social Services Annual ReportFootnote xi.
The Minister appoints the Chair of the Leadership Council as well as the chairperson and members of each Regional Wellness Council. The chairpersons and members of the Regional Wellness Councils may serve for three years and may be re-appointed to serve another term.
The Minister may appoint a Public Administrator to assume the role of a Board of Management in certain circumstances if the Minister feels it is necessary. During 2021-2022, a Public Administrator was in place for the Hay River Health and Social Services Authority. The Public Administrator acts in the place of a Board of Management.
The Tłı̨chǫ Community Services Agency was established under the Tłı̨chǫ Community Services Agency Act as part of the Tłı̨chǫ Land Claims and Self Government Agreement. The Tłı̨chǫ Community Services Agency Act, which is administered by the Minister of Executive and Indigenous Affairs, stipulates that the Tłı̨chǫ Community Services Agency has all the powers, duties and functions of a Board of Management under the Hospital Insurance and Health and Social Services Administration Act. Under the Tłı̨chǫ Community Services Agency Act, each Tłı̨chǫ community government is responsible for appointing one board member and the Minister of Executive and Indigenous Affairs is responsible for appointing the Chairperson following a consultation with the board members. The term for Tłı̨chǫ Community Services Agency board members is a maximum of four years with the Chairperson's term being fixed by the Minister of Executive and Indigenous Affairs.
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.
In accordance with the Financial Administration Act and the Hospital Insurance and Health and Social Services Administration Act, there is an obligation to report to the Legislative Assembly on the preceding year's operations and financial position of the Department. Each year the NWT Health and Social Services System Annual Report meets these obligations, as well as meets the obligation to annually report on the operations of the Medical Care Plan.
The Office of the Auditor General of Canada (OAG) audits payments made under the NWT Hospital Insurance Plan and the NWT Medical Care Plan through their annual audit of the Government of the NWT's Public Accounts.
The Hospital Insurance Plan and the Medical Care Plan are administered by the Department. The latest OAG audit was on the 2020-2021 Public Accounts Section I: Consolidated Financial Statements and was completed as of November 29, 2021. The GNWT, Public Accounts 2020-2021 Section I: Consolidated Financial Statements was published on December 8, 2021.
Insured hospital services in the Northwest Territories (NWT) are provided under the Hospital Insurance and Health and Social Services Administration Act. No amendments were made to the legislation or regulations in 2021-2022.
During the reporting period, insured hospital services were provided to in-patients and out-patients by 23 facilities throughout the NWT. Consistent with Ssection 9 of the Canada Health Act, the NWT offers a comprehensive range of insured services to its residents.
Insured in-patient hospital services include:
Insured out-patient hospital services include:
The Minister of Health and Social Services (the Minister) may approve additions or deletions to insured services provided in the NWT. While there were no changes to insured services in 2021-2022, assessment of additions is accomplished on a case-by-case basis. The Director of Medical Insurance makes such determinations based on the advice of the Medical Advisor. This process is a ‘right size’ approach, scaling the complexity of decision making to be appropriate to the size of the NWT health and social services system. Public consultation can be carried out through Regional Wellness Councils.
As outlined in the Government of the NWT Medical Travel Policy, travel assistance is provided to residents with a valid NWT Health Care Card who require medically necessary insured services that are not available in their home community.Footnote xii This ensures that residents of the NWT have reasonable access to insured hospital and physician services and that the cost of travel is not a barrier to care.
The NWT does not have any private diagnostic clinics that charge patients for services that would be considered insured if provided in a hospital.
The NWT Medical Care Act and the NWT Medical Care Regulations provide for insured physician services. Medically necessary services provided in approved facilities by physicians, nurses, nurse practitioners, and midwives are considered insured services under the NWT Health Care Plan. These professionals are required by legislation to be licensed to practice in the NWT under the Medical Profession Act (physicians), Nursing Profession Act (nurses and nurse practitioners) and Midwifery Profession Act. There were no amendments made to the legislation in 2021-2022.
For the period 2021–2022 there were 421 licensed physicians (resident, locum and visiting) active in the NWT.
Physicians may opt out and collect fees other than under the NWT Medical Care Plan by providing written notice to the Director of Medical Insurance. There were no opted-out physicians in the NWT during the reporting period.
The NWT Medical Care Plan insures all medically necessary physician services such as:
Services not insured include:
The Director of Medical Insurance is responsible for recommending an insured services tariff for services payable by the NWT Medical Care Plan for the Minister's approval. The Minister ultimately determines if services will be added, altered, or removed from the tariff by:
While there were no changes to insured services in 2021-2022, assessment of additions is accomplished on a case-by-case basis. The Director of Medical Insurance makes such determinations based on the advice of the Medical Advisor. This process is a ‘right size’ approach, scaling the complexity of decision making to be appropriate to the size of the NWT health and social services system. Public consultation is readily available through Regional Wellness Councils.
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.
Dentists are unable to participate in the NWT Medical Care Plan except where medically necessary and when services are delivered in a hospital. Dentists, when delivering services in a hospital, bill third-party insurance providers for dental surgery, and the anaesthetic services are covered under the NWT Medical Care Plan.
The only surgical-dental related procedures, covered under insured services, are for procedures focusing on reconstructive surgery of the face, primarily of the mouth and jaw as a result of trauma or birth defect. Such procedures are not identified as dental surgery but are identified as medically necessary surgery and are subject to physician referral. No procedures were added in 2021-2022 to the list of insured surgical services covered by the NWT Medical Care Plan.
Not all services provided by hospitals, medical practitioners and dentists are covered under the NWT Health Care Plan. Some uninsured services include:
Prior approval is required for NWT residents to receive items, services, or both, that are generally considered uninsured under the NWT Health Care Plan. A Medical Advisor makes recommendations to the Director of Medical Insurance regarding the appropriateness of the request.
The Workers' Safety and Compensation Commission (WSCC) covers the costs of the services to treat a worker who is injured on the job according to WSCC policy. The policy that covers requirements for entitlement can be found in NWT and Nunavut WSCC, Policy Manual, (Policy 03.02) available on the Workers' Safety and Compensation Commission site.
Changes to the list of uninsured hospital, physician, and surgical-dental services may be made by the Minister. While there were no changes to uninsured services in 2021-2022, assessment of additions is accomplished on a case-by-case basis. The Director of Medical Insurance makes such determinations based on the advice of the Medical Advisor. This process is a ‘right size’ approach, scaling the complexity of decision making to be appropriate to the size of the NWT health and social services system. Public consultation is readily available through Regional Wellness Councils.
The Medical Care Act and the Hospital Insurance and Health and Social Services Administration Act define eligibility for the Northwest Territories (NWT) Health Care Plan. The NWT Health Care Plan uses guidelines that are consistent with the legislation and the Interprovincial Agreement on Eligibility and Portability to determine eligibility to fulfill obligations of section 10 in the Canada Health Act.
Every resident is, on the first day of the third month after becoming a resident, eligible for and entitled to payment of benefits in respect of insured services rendered to the resident in accordance with the Medical Care Act and Medical Care Regulations. Military families are exempt from the three-month waiting period and are eligible for coverage their first day in the Territory.
According to the Medical Care Act, a resident is a person lawfully entitled to be or to remain in Canada, who makes their home and is ordinarily present in the NWT, but does not include a tourist, transient, or visitor to the NWT. There were no amendments to the Medical Care Act regarding eligibility made in 2021-2022.
To register for the NWT Health Care Plan, residents fill out an application form and provide relevant supporting documentation (e.g., visa, immigration papers, and proof of residency). Residents may register prior to the date they become eligible. Registration is directly linked to eligibility for coverage and claims are only paid if the client has registered.
Coverage begins when a signed application has been approved.
Residents can opt out of the NWT Health Care Plan if they choose not to register. There is nothing in the Medical Care Act that requires a resident to register for the NWT Health Care Plan. At any time, a resident may advise the NWT Health Care Plan administrator of a wish to opt out of the Plan.
Eligible people are those who have established permanent residency in the NWT, members of the Royal Canadian Mounted Police residing in the NWT, dependents of a member of the Canadian Armed Forces residing in the NWT, returning Canadians or returning Permanent Residents (a person who has immigrated to Canada with permanent resident status through Citizenship and Immigration Canada), and individuals working at a mine site who do not maintain a permanent residence in another province.
Individuals not eligible for NWT health care coverage are members of the Canadian Forces, federal inmates, and new residents who have not completed the minimum waiting period.
In accordance with the Interprovincial Agreement on Eligibility and Portability of Hospital and Medical Care Insurance, residents who have been federal inmates become eligible upon release to the NWT; permanent residents become eligible upon establishment of permanent residency. Returning Canadians are eligible on the first day of arrival in NWT and permanent residents are also eligible on the first day, provided that the NWT is the first jurisdiction they are residing in upon arriving in or returning to Canada.
If an application for an NWT Health Care Card is denied, coverage is denied for a procedure, or if a person is appealing the decision to cancel their NWT Health Care Card, individuals may appeal to the Director of Medical Insurance. Second level and final appeals may be directed to the Deputy Minister of Health and Social Services.
As of March 31, 2022, there were 43,902 individuals registered with the NWT Health Care Plan.
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 NWT Health Care Plan coverage.
Babies born to NWT residents outside of Canada are automatically covered effective on the date of birth, if:
Foreign students and workers are eligible for coverage if they hold study or work permits valid for a period of 12 months or longer. Those holding permits of less than 12 months are not eligible for coverage.
Permanent residents (landed immigrants) and returning permanent residents, including those with expired residency, are covered on the first day of arrival in the NWT provided the NWT is their first place of residence in Canada, and they intend to reside in the NWT.
Convention refugees are covered, provided they provide appropriate documentation.
The following are not eligible for an NWT Health Care Card as they are not considered residents:
Waiting periods for persons moving to the Northwest Territories (NWT) are consistent with the Interprovincial Agreement on Eligibility and Portability. The waiting period ends the first day of the third month of residency for those moving permanently to the NWT. Military families are exempt from the three- month waiting period and are eligible for coverage their first day in the NWT.
Section 4(2) of the Medical Care Act provides NWT residents with access to insured health coverage while temporarily out of the NWT but still in Canada, consistent with section 11(1) (b)(i) of the Canada Health Act. The Department of Health and Social Services (the Department) adheres to the Interprovincial Agreement on Eligibility and Portability. No amendments were made in 2021-2022 to the Medical Care Act.
NWT residents may be covered for up to one year of temporary absence for work, travel or holidays. Full-time students attending post-secondary school are covered. The full cost of insured services is paid for all services received in other Canadian jurisdictions. The criterion for Temporary Absence is that the individual must be physically present in the NWT for a period of 153 days in a calendar year to maintain residency.
When a valid NWT Health Care Card is produced, most doctor visits and hospital services are billed directly to the Department. During the reporting period, approximately 28.7 million dollars were paid out for hospital in-patient and out-patient services in other provinces and territories. Reimbursement guidelines exist for patients having to pay up front for medically necessary services.
The NWT participates in both the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement with other jurisdictions (except Quebec).
As per section 4(3) of the Medical Care Act and section 11(1)(b) (ii) of the Canada Health Act, the NWT provides reimbursement for NWT residents who require medically necessary services while temporarily outside Canada. No amendments were made in 2021-2022 to the Medical Care Act.
Individuals are required to pay up front and seek reimbursement upon their return to the NWT. Costs for eligible services, including in-patient services, out-patient services, and haemodialysis rendered outside Canada, will be reimbursed up to the amounts payable in the NWT.
Residents temporarily out of Canada may receive coverage for up to one year; however, prior approval as well as documentation proving the NWT will be the individual's permanent residence upon return is required. Returning Canadians are covered on the first day of arrival in the NWT. Documentation is required to validate the first day of arrival. Permanent residents (Landed immigrants) are covered on the first day of arrival in the NWT, with appropriate documentation from Immigration Canada, provided the NWT is their first place of residence in Canada and they intend to reside here. Foreign workers holding a valid closed work permit are eligible for coverage on the first day they are present in the NWT. Live-in care givers with a work permit that lists the NWT as the location of employment are eligible for first day coverage. Military families are also eligible for first day coverage.
Prior approval is required for elective services rendered in other provinces and outside Canada. All services from private facilities require prior approval.
First level appeals of decisions may be sent to the Director of Medical Insurance. Second level appeals are considered by the Deputy Minister of Health and Social Services. The decision of the Deputy Minister is final.
The Northwest Territories (NWT) Medical Travel Policy provides NWT residents with assistance to access medically necessary insured services not available in their home community consistent with section 12(1)(a) of the Canada Health Act.
Extra-billing is not permitted in the NWT, in adherence to section 18 of the Canada Health Act and section 14(1) of the Medical Care Act. The only exception is if a medical practitioner opts out of the NWT Medical Care Plan and collects his or her own fees. Extra-billing did not occur in 2021-2022.
User charges are also not permitted under section 14(2) of the Medical Care Act unless the medical practitioner has opted-out of the NWT Medical Care Plan, collects his or her own fees, and gives reasonable notice of the intention to collect fees.
The Medical Care Act includes a provision to allow the Minister of Health and Social Services (the Minister) to establish a Benefits Appeal Committee that could address any matter referred to it by the Minister, including complaints where a physician engaged in extra-billing and charged user fees. This committee has not been established.
Complaints of extra-billing or user charges can be made to: The Health Services Administration Office, Health and Social Services Bag#9, Inuvik NT, X0E OTO by phone at: 1-800-661-0830 or 1-867-777-7400 or by Fax at: 1-867-777-3197
In 2021-2022, Primary Health Care Reform (PCHR) continued despite some temporary delays due to COVID-19. PCHR is intended to enhance primary health care in the NWT through the lens of cultural safety and patient-centered care by focusing on building relationships with individuals and their families. Building on the work done in several regions of NWT (Dehcho, Fort Smith, Tłı̨chǫ, and Yellowknife), early-stage work progressed in 2021-2022 to expand PCHR demonstration projects to other regions of the NWT (Beaufort Delta, Hay River and Sahtu).
The Department of Health and Social Services (the Department), in consultation with the NWT Medical Association, sets physician compensation. Generally, family and specialist practitioners are compensated through contractual agreements with the Government of NWT, while the remaining practitioners are compensated on a fee-for-service basis. Fee-for-service rates in the NWT are itemized in the Insured Services Tariff approved by the Minister in accordance with the Medical Care Act.
Under the Medical Care Act, the Minister may appoint medical and financial inspectors who shall, under the direction of the Director, inspect, examine, and audit books, accounts, reports, and medical records maintained in hospitals, health facilities, offices of medical practitioners, and other health care facilities respecting patients who are receiving or who have received insured services. The Director may reassess an account for insured services submitted by a medical practitioner and make any appropriate adjustment in the amount paid to the medical practitioner in respect of the insured services.
Contribution agreements between the Department and the Boards of Management dictate payments made to hospitals. Government budgets, resources, and levels of services offered determine the allocated amounts.
Payments for the provision of 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 developed to fund hospitals in the NWT.
Federal funding from the Canada Health Transfer has been recognized and reported by the Government of the Northwest Territories (GNWT) through the following documents: GNWT, Interim Public Accounts for the year ended March 31, 2021 (published November 29, 2021), GNWT, Public Accounts 2020-2021 Section I: Consolidated Financial Statements (published December 8, 2021), and GNWT, 2022-2023 Main Estimates (published February 22, 2022).
The Public Accounts contain the consolidated financial statements of the GNWT, audited by the Auditor General of Canada, and are presented annually to the Legislative Assembly. The Main Estimates are also presented annually to the Legislative Assembly.
All data are subject to future revisions.
Payments for insured health services are estimated and include only those health services occurring within acute care facilities (i.e., hospitals that offer both in-patient and outpatient services).
Return to footnote 1 referrer
2018-19 is the first year Health Canada required reporting preapproved versus non pre-approved claims and expenditures. Prior to 2018-19 all out of Canada claims are included in the non pre-approved category.
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Estimate based on total active physicians for each fiscal year.
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Payments are based on an estimate of expenditures for physician services on NWT residents (including physician remuneration and clinic costs).
Return to footnote 4 referrer
2018-19 is the first year Health Canada required reporting preapproved versus non pre-approved claims and expenditures. Prior to 2018-19 all out of Canada claims are included in the non pre-approved category.
Return to footnote 5 referrer
The Department of Health (the Department) faces many unique challenges when providing for the health and well-being of Nunavummiut. Of a total population of 39,403 approximately one third of the population is under the age of 15 years. The territory is made up of 25 communities located across three time zones and divided into three regions: the Qikiqtani (or Baffin), the Kivalliq and the Kitikmeot.
The Government of Nunavut incorporates Inuit Societal Values into program and policy development, as well as into service design and delivery. The delivery of health services in Nunavut is based on a primary health care model. Nunavut's primary health care providers are family physicians, nurse practitioners, midwives, community health nurses, and other allied health professionals.
In 2021-2022, the territorial operations and maintenance budget for the Department was $488,227,000 including supplementary appropriations. One third of the Department's total operational budget was spent on costs associated with medical travel and treatment provided in out-of-territory facilities. Nunavut is a vast territory with a low population density and limited health infrastructure, therefore, access to a range of hospital and specialist services often requires that residents be sent out-of-territory for care.
In 2021-2022, a total of $24,550,000 was allocated to the Department for capital projects. The Department's 2021-2022 capital projects include the construction of the new community health centre in Kinngait and the long-term care facility in Rankin Inlet.
The Health Care Insurance Plans of Nunavut, including physician and hospital services, are administered by the Department of Health (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 is responsible for delivering health care services to Nunavummiut, including the operation of community health centres, regional health centres, and a hospital. There are three regional offices that manage the delivery of health services at a regional level. Iqaluit operations are administered separately. The Government of Nunavut opted for decentralization to regional offices to support front-line workers and community-based delivery of a wide range of health programs and services.
Legislation governing the administration of health services in Nunavut was carried over from the Northwest Territories (as Nunavut statutes) pursuant to the Nunavut Act. The Medical Care Act governs who is covered by the Nunavut Health Care Plan and the payment of benefits for insured medical services. Section 23(1) of the Medical Care Act requires the Minister responsible for the Act to appoint a Director of Medical Insurance.
The Director is responsible for the administration of the Act and its Regulations. Section 24 requires the Director to submit an annual report on the operation of the Nunavut Health Care Plan to the Minister for tabling in the Legislative Assembly. The Operation of the Medical Care Plan (PDF document) from the Director of Medical Insurance was submitted and is available on the Department's website.
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 consolidated financial statements of the Government of Nunavut. The most recent audit of the Government of Nunavut's public accounts was completed on October 20, 2021, for the fiscal year 2020-2021. The Independent Auditor's Report to Nunavut's Legislative Assembly can be found on page 19 of the Government of Nunavut's Report of Public Accounts.
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 2021-2022.
In 2021-2022, insured hospital services were delivered in 28 facilities across Nunavut including:
The QGH is currently the only acute care facility in Nunavut, accredited by Accreditation Canada, providing a range of in-and out-patient hospital services as defined by the Canada Health Act. QGH offers 24-hour emergency services, in-patient care (including obstetrics, pediatrics and palliative care), surgical services, laboratory services, diagnostic imaging, respiratory therapy, rehabilitation services, and health information management services.
Currently, Rankin Inlet is providing 24-hour care for in-patients; out-patients receive care by on-call staff. Cambridge Bay is providing daily clinic hours, and emergency care is available, on-call, 24-hours a day. There are also a limited number of birthing beds at both facilities.
Other community health centres provide public health services, out-patient services, and urgent treatment services.
Public health services are provided at public health clinics located in Rankin Inlet and Iqaluit. Public health programing is provided in the remaining communities through the local health centre. The Department of Health (the Department) also operates a Family Practice Clinic in Iqaluit. This clinic operates as part of the primary care program at QGH.
The Department is responsible for authorizing, licensing, inspecting and supervising all health facilities in the territory.
Insured in-patient hospital services include:
Out-patient services include:
The Department makes the determination to add insured hospital services based on the availability of appropriate resources, equipment, and overall feasibility in accordance with financial guidelines set by the Department and with the approval of the Financial Management Board. The Commissioner of Nunavut, with their authority, may also make regulations prescribing insured services. No new services were added in 2021-2022 to the list of insured hospital 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 Regulation in 2021-2022. The Nursing Act allows for licensure of nurse practitioners in Nunavut; this permits nurses to deliver insured services in Nunavut. A review of the Nursing Act began in 2021-2022.
Upon initial registration, physicians must be in good standing with a College of Physicians and Surgeons from a Canadian jurisdiction to be licensed to practice in Nunavut. The Government of Nunavut's Medical Registration Committee currently manages this process for Nunavut physicians. Nunavut recruits and contracts its own family physicians and accesses specialist services primarily from its main referral centres in Ottawa, Edmonton, Winnipeg, and Yellowknife. There are 40.5 family physician positions, which are covered by a combination of locums and full-time physicians. Recruitment of full-time family physicians has become an increasing challenge and remains a high priority for the Department. In 2021-2022, family physicians provided over 9,530 days of service across the territory.
Of the 40.5 full-time family physician positions in Nunavut, 24.5 are in the Qikiqtaaluk region; 11 in the Kivalliq region; and five in the Kitikmeot region. There are also three general surgeon positions, two general practitioner anesthetist positions, and four pediatrician positions at the QGH. Visiting specialists, general practitioners, and locums also provide insured physician services; these arrangements are made by the Department's Medical Affairs division, in consultation with regional leadership.
Physicians can elect to collect fees other than those under the Medical Care Plan as per section 12(2) (a) or (b) of the Medical Care Act by notifying the Director of Medical Insurance (the Director) in writing. An election can be revoked on the first day of the following month after a letter to that effect is delivered to the Director. In 2021-2022, no physicians provided written notice of this election. All physicians practicing in Nunavut are under contract with the Department. In 2021–2022, 127 physicians provided services in Nunavut.
Insured physician services refer to all services rendered by medical practitioners that are medically required. Where insured services are unavailable in some places in Nunavut, the patient is referred to another jurisdiction to obtain the insured service. Nunavut has health service agreements with medical and treatment centres in Ottawa, Winnipeg, Churchill, Yellowknife, and Edmonton. These are the out-of-territory sites to which Nunavut mainly refers its patients to access medical services not available within the territory.
The following is a list of common insured categories as per Nunavut's Medical Care Regulations. Services provided under these categories are considered insured if the medically required diagnosis and/or treatment is provided in-territory or out-of-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 removed in 2021-2022.
Dentists providing insured surgical-dental services under the Nunavut Health Care Plan must be licensed pursuant to the Dental Professions Act (NWT, 1988 and as duplicated for Nunavut by section 29 of the Nunavut Act, 1999). Billing numbers are provided for billing the Plan regarding the provision of insured dental services.
Insured dental services are limited to those dental-surgical procedures scheduled in the Regulations, requiring the unique capabilities of a hospital for their performance; for example, orthognathic surgery. The Department insures all dental-surgical services outlined in provincial/territorial reciprocal billing agreements. 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. Dentists travelling to Nunavut to deliver services are under contract with the Government of Nunavut and do not have the option to opt-out.
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 2020–2021.
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:
Services not covered in a hospital include:
In 2021-2022, the Qikiqtani General Hospital charged a $2,885 per diem rate for services provided for non-Canadian resident stays. The in-patient rate charged in Rankin Inlet and Cambridge Bay was $1,620 per day.
When residents are sent out-of-territory for services, the Department relies on the policies and procedures guiding that particular jurisdiction when they provide services to Nunavut residents that could result in additional costs, only to the extent that these costs are covered by Nunavut's Medical Insurance Plan (see section 4.2 below). Any query or complaint is handled on an individual basis with the jurisdiction involved.
The Department also administers the Non-Insured Health Benefits (NIHB) Program, on behalf of Indigenous Services 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.
Eligibility for the Nunavut Health Care Plan is briefly defined under sections 3(1), (2), and (3) of the Medical Care Act. The Department of Health (the Department) also adheres to the Interprovincial Agreement on Eligibility and Portability, as well as internal guidelines. No amendments were made to the Act or Regulations in 2021-2022.
Subject to these provisions, every Nunavut resident is eligible for and entitled to insured health services on uniform terms and conditions. A resident means a person lawfully entitled to be in or to remain in Canada, who makes their home and is ordinarily present in Nunavut, but does not include a tourist, transient or visitor to Nunavut. Eligible residents receive a health card with a unique health care number.
Registration requirements include a completed application form and supporting documentation. A health care card is issued to each resident. To streamline document processing, a staggered renewal process is used. No premiums exist. Coverage under the Nunavut Medical Insurance Plan is linked to verification of registration, although every effort is made to ensure registration occurs when a coverage issue arises for an eligible resident. For non-residents, a valid health care card from their home province or territory is required.
Coverage generally begins the first day of the third month after arrival in Nunavut, but first-day coverage is provided under a number of circumstances, for example, newborns whose mothers or fathers are eligible for coverage. Permanent residents (landed immigrants), returning Canadians, repatriated Canadians, returning permanent residents, and non-Canadians who have been issued an employment visa for a period of 12 months or more, are also granted first-day coverage.
Members of the Canadian Armed Forces and inmates of a federal penitentiary are not eligible for registration. These groups are granted first-day coverage under the Nunavut Health Care Plan upon discharge.
Pursuant to section 7 of the Interprovincial Agreement on Eligibility and Portability, individuals in Nunavut who are temporarily absent from their home province or territory and who are not establishing residency in Nunavut remain covered by their home provincial or territorial health insurance plans for up to one year.
On March 31, 2022, 40,586 individuals were registered with the Nunavut Health Care Plan, an increase of 641 from the previous year. There are no formal provisions for Nunavut residents to opt-out of the Nunavut Health Care Plan, and no legislated appeals process, or policy related to appeals of residency or coverage decisions.
Categories of individuals not eligible for coverage include:
Children born out-of-country to Canadian citizens are covered only when they return to Nunavut. Returning residents (whose residency has expired) would be covered if proof of residency is provided.
When unique circumstances occur, assessments are done on an individual basis. This is consistent with section 15 of the Northwest Territories' Guidelines for Health Care Plan Registration, which was adopted by Nunavut in 1999.
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.
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 of Health 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 2021-2022 with respect to coverage outside Nunavut.
Students studying outside Nunavut must notify the Department of Health (the Department) and provide proof of enrollment to ensure continuing coverage. Requests for extensions must be renewed yearly and are subject to approval by the Director of Medical Insurance (the Director). Temporary absences for work, vacation or other reasons for up to one year are approved by the Director upon receipt of a written request from the insured person. The Director may approve absences in excess of 12 continuous months upon receiving a written request from the insured individual.
The provisions regarding coverage during temporary absences in Canada fully comply with the terms and conditions of the Interprovincial Agreement on Eligibility and Portability. Nunavut participates in physician and hospital reciprocal billing. As well, health service agreements are in place with Ontario, Manitoba, Alberta, and the Northwest Territories. The Hospital Reciprocal Billing Agreements provide payment of in-patient and out-patient hospital services to eligible Nunavut residents receiving insured services out-of-territory. High-cost procedure rates, newborn rates, and out-patient rates are based on those established by the Interprovincial Health Insurance Agreements Coordinating Committee. The Physician Reciprocal Billing Agreements provide payment of insured physician services on behalf of eligible Nunavut residents receiving insured services out-of-territory. Payment is made to the host province or territory at the rates established by that province or territory.
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. No amendments were made in 2020-2021 to either Act respectively. Nunavut residents 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. No exceptions are made to this process for specific categories of individuals as all cases are addressed individually. For services provided to residents who have been referred out-of-country for highly specialized procedures unavailable in Nunavut and Canada, Nunavut will pay the full cost. For emergency services, the payment for hospital services is $2,885 per day and for out-patient care it is $322 per day.
Insured physician services provided to eligible residents temporarily outside the country are paid at rates equivalent to those paid had that service been provided in the territory. Reimbursement is made to the insured individual or directly to the provider of the insured service.
Prior approval is required to receive reimbursement for elective services provided in private facilities in Canada or in any facility outside the country. There are no processes related to pre-approval appeals for out-of-jurisdiction coverage.
The Medical Care Act, section 14, prohibits extra-billing by physicians unless the medical practitioner has made an election that is still in effect. Access to insured services is provided on uniform terms and conditions. To break down the barrier posed by distance and cost of travel, the Government of Nunavut provides medical travel assistance. Interpretation services in Inuktut are also provided to patients. The Department of Health (the Department) does not have a specific complaints office solely for extra-billing. However, the Department has other mechanisms for Nunavummiut to register concerns regarding their health care service and can be reached at:
[email protected] Nunavut Health Insurance Programs Office
Department of Health Box 889 Rankin Inlet, NU X0C 0G0
Toll Free: 1 800-661-0833
Concerns raised regarding extra-billing that have occurred within Nunavut are fully investigated and addressed with disciplinary action if warranted. If extra-billing has occurred out-of-territory, it is up to the jurisdiction where it has occurred to investigate and address.
The Qikiqtani General Hospital, a site of Iqaluit Health Services is currently the only acute care hospital facility in Nunavut. The hospital has a total of 20 beds available for acute, medical, surgical, pediatric, rehabilitative, palliative, and chronic care services. There are also four birthing rooms, two post anesthesia care beds, and five-day surgery beds. The facility provides in-patient, out-patient, and 24-hour emergency services. On-site physicians provide emergency services on rotation. Medical services provided include: an ambulatory care/out-patient clinic emergency trauma response and stabilization services, pediatric services, and general medical, maternity, and palliative care. On-site specialists include: pediatrics, general surgery and gynecology. Visiting specialist services provided include ophthalmology, urology, orthopedics otolaryngology, and dental surgery under general anaesthesia and conscious sedation. Patients requiring complex specialized surgeries are sent to other jurisdictions. Diagnostic services include: digital diagnostic imaging, laboratory, electrocardiogram, and CT scans.
Outside of Iqaluit, out-patient and 24-hour emergency nursing services are provided by local health centres in Nunavut's 24 other communities.
Nunavut has three continuing care centres located in Gjoa Haven, Igloolik and Cambridge Bay. These facilities provide full-time nursing and personal care to adults. The Gjoa Haven and Igloolik facilities have 10 beds each, and the Cambridge Bay facility has 8 beds.
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 2021-2022 under the visiting specialists program: ophthalmology, orthopedics, internal medicine, otolaryngology, neurology, rheumatology, dermatology, pediatrics, obstetrics/gynecology, urology, respirology, cardiology, total joint assessment clinic (TJAC), sleep study, oral surgery, plastic surgery, and allergist. Visiting specialist clinics are scheduled in advance and are offered on specific weeks throughout the year. Due to COVID-19 restrictions, in-person specialist clinics were reduced, canceled, or postponed in response to COVID-19 outbreaks. Virtual care was used whenever feasible.
Nunavut's Telehealth network, linking all 25 communities, allows for the delivery of a broad range of services over distances including specialist consultation services such as dermatology, psychiatry and internal medicine; rehabilitation services; regularly scheduled counseling sessions; family visitation; and continuing medical education. The long-term goal is to integrate Telehealth into the primary care delivery system, enabling residents of Nunavut greater access to a broader range of service options, and allowing service providers and communities to use existing resources more effectively.
For services and equipment unavailable in Nunavut, patients are referred to other jurisdictions.
All full-time physicians in Nunavut work under contract with the Department. The Medical Care Act section.5.1(1) states "the Director, in accordance with this Act and the regulations, may enter into agreements, as the Director considers necessary, for services, including insured services, provided on an other than fee-for-service basis. The terms of the contracts are set by the Department. Visiting consultants are paid a daily contract rate for their professional services. Rates vary based on services rendered. The Department complies with the Financial Administration Act and Financial Administration Manual in monitoring or auditing remuneration.
Funding for the Qikiqtani General Hospital, regional health facilities, and community health centres is provided through the Government of Nunavut's budget process.
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 2020-2021, they included the 2020-2021 Fiscal and Economic Indicators and the 2020-2023 Government of Nunavut and Territorial Corporations Business Plan.
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.
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Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years. The claims are for genetic testing provided out of country
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This figure captures the number of general practitioners providing services in Nunavut. The total does not include specialist services.
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Nunavut does not pay its physicians through fee-for-service. Instead, physicians in Nunavut are compensated through contracted salaries.
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Health Canada requested this information be disaggregated into pre-approved and non pre-approved data as of the 2018-2019 report, but did not require provinces or territories to report on previous years.
Return to footnote 5 referrer
This annex provides the reader with an office consolidation of the Canada Health Act and the Extra-billing and User Charges Information Regulations. An office consolidation is a rendering of the original Act, which includes any amendments that have been made since the Act's passage. The only regulations in force under the Act are the Extra-billing and User Charges Information Regulations. These Regulations require the provinces and territories to provide estimates of extra-billing and user charges prior to the beginning of each fiscal year so that appropriate penalties can be levied, as well as financial statements showing the amounts actually charged so that reconciliations with any estimated charges can be made. These Regulations are also presented in an office consolidation format. This unofficial consolidation is not necessarily current and is provided for the convenience of the reader only. For the official text of the Canada Health Act, please contact Justice Canada.
Links to Canada Health Act and Regulations:
The Canada Health Act and Extra-billing and User Charges Information Regulations require provinces/territories to report annually to the federal Minister of Health. This report takes the form of a financial statement of actual amounts of extra-billing and user charges levied in the province/territory for the fiscal year in question, along with an explanation regarding the method used to determine the reported amount as indicated in below.
The information reported in the financial statements may be used to determine amounts deducted from the Canada Health Transfer payments of a province/territory where extra-billing and user charges are occurring. However, pursuant to Section 20 of the Act, the federal Minister of Health may estimate amounts of extra-billing and user charges levied, if there is evidence that the information reported in the financial statement does not accurately reflect amounts actually charged to patients in the province or territory.
Under the Act, Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan
Under the Act, a user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
While Quebec did not submit a financial statement in the standard form provided, amounts of extra-billing and user charges levied in the province during 2019-2020 were confirmed in the form of two letters, which are reproduced in this annex
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services:
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 1,723.41
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 1,723.41
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below.
In Newfoundland and Labrador, the Department of Health and Community Services (HCS) administers the Medical Care Plan (MCP). Subsection 7(1) of the Medical Care and Hospital Insurance Act states that a practitioner shall not charge or collect from a beneficiary a fee for those insured services in excess of the amounts payable under this Act and the regulations. Administration of the Medical Care Plan, including deterrence of extra-billing, is in accordance with the Act and the associated regulations. Of particular note are the Medical Care Insurance Insured Services Regulations, NLR 21/96 (the "Regulations").
Section 25 of the Medical Care and Hospital Insurance Act provides the Minister with powers to recover overpayments and interest that were discovered via audit. The Minister of Health and Community Services may do this by entering into an agreement with the practitioner to pay to the Minister the overpaid amount plus interest.
On June 15, 2018, an amendment was made to section 3 of the Medical Care Insurance Insured Services Regulations to clarify that "the medically necessary removal and replacement of a cataractous lens by any procedure is an insured service and shall be performed in a hospital or a facility designated by the Lieutenant-Governor in Council."
On January 12, 2021, two non-hospital facilities were approved to provide insured cataract surgery. The policy below outlines the requirements for these designated non-hospital facilities: Policy-for-the-Provision-of-Cataract-Surgery-in-Non-Hospital-Designated-Facilities-1.pdf (gov.nl.ca).
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below.
HCS conducts regular audits of provider billings. No instances of extra-billing or user charges (EBUC) were identified during the relevant period through the regular auditing process.
Cases of EBUC may be identified through the audit process described under section 21 of the Medical Care and Hospital Insurance Act or may be reported by beneficiaries. These instances may be discovered when beneficiaries submit claims for reimbursement to the Medical Care Plan (MCP) or make enquiries for services when payment is requested.
Complaints from beneficiaries regarding charges for insured health services are managed by the Department. Depending on the circumstance, the Department may investigate or refer the matter to the College of Physicians and Surgeons of Newfoundland and Labrador, the regulatory body for physicians in the province, for potential disciplinary action. Beneficiaries may also contact the College directly if they feel that they have been subject to improper billing by their physician. Information regarding complaints can be found at Complaints & Discipline - CPSNL.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
In 2017-2018, HCS received complaints from beneficiaries of direct billing for cataract surgery. HCS issued a Public Service Announcement on February 7, 2018 inviting individuals to contact HCS with suspected instances of EBUC related to cataract surgery in an effort to better understand the issue.
On February 20, 2020, HCS published a Public Advisory on the Reimbursement Process for Cataract Surgeries. To be eligible for reimbursement of fees paid for cataract surgery, patients must submit documents indicating that insured cataract surgery was paid for outside of a hospital or designated facility before June 15, 2018. Patients who had previously submitted documents indicating eligibility for reimbursement were contacted by HCS to arrange payment. HCS also identified other beneficiaries that could be eligible for reimbursement but whose supporting documents were inconclusive or unavailable. HCS invited these individuals to submit documents for review to determine eligibility.
Despite the requirement for services to be provided prior to June 15, 2018 for reimbursement, HCS did receive enquiries for reimbursement for services received after June 15, 2018. To better understand this issue, HCS did invite these patients to provide such documents for review. Through review of submitted documents, as well as billing data when available, HCS has identified a total of two patients (representing three eyes) that appear to have paid for insured cataract surgery for this reporting period. Submitted documents include self-reported symptoms as well as supporting medical documents from other health care providers.
Review of available billing data from patients who contacted HCS for reimbursement for procedures after June 15, 2018 revealed that claims with the ICD-9 diagnostic code for "cataract" were also billed to MCP for services provided to patients who understood that they were paying out-of-pocket for cataract surgery. Claims billed to MCP include diagnostic services and consultations. Claims are submitted with service dates prior to, the day of, and following the identified procedures in the private clinic.
Review of detailed invoices indicate that the service provided and billed to the patients for this reporting year was "ASC-Surgery-Custom Premium Vision Correction". The invoices clearly state that the services provided were "non-insured. All premium self-pay procedures / diagnostic tests / medications are optional and are not eligible for MCP reimbursement". Amounts billed to the patient include premium vision correction ($2,795) and femto technology ($1,200) for a total of $3,995. The premium vision correction amount of $2,795 seems to represent the cost of an "extended range of vision custom multifocal intraocular lens" ($1,800), as well as various non-insured diagnostics ($970), and a post-surgical refractive lens kit ($25). Removal of the natural lens was not charged to the patients.
The professional fee for the insured removal of a cataractous lens in Newfoundland and Labrador is $473.09. The fee payable for insured replacement with an intraocular lens is $101.38. The total professional fees payable for removal and replacement of a cataractous lens is $574.47. Because there were three eyes operated on for this reporting period, the total user charges reported are $574.47 X 3 = $1,723.41.
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below.
Section 7 of the Medical Care and Hospital Insurance Act outlines that a practitioner who provides insured services, whether or not he or she has made an election to opt out of participation in the MCP, shall not charge or collect from a beneficiary a fee for those insured services in excess of the amount payable under the Act and the regulations. A practitioner or other person who contravenes this is guilty of an offence and liable on summary conviction to a fine of up to, but not more than $20,000 for each contravention.
The Medical Care and Hospital Insurance Act authorizes the Minister to appoint auditors to audit the accounts and claims for payments submitted by physicians and dentists. The Act prescribes the power and duties of auditors, sets out the remedies available and details the processes to be followed. The Act also details the review and appeal processes available to practitioners. Individual providers are randomly selected on a biweekly basis for audit.
On January 12, 2021, two non-hospital facilities were approved to provide insured cataract surgery. The policy below outlines the requirements for these designated non-hospital facilities: Policy-for-the-Provision-of-Cataract-Surgery-in-Non-Hospital-Designated-Facilities-1.pdf (gov.nl.ca).
Section 14.1 of the policy specifically deals with expectations regarding EBUC, which are prohibited. The ophthalmologist has a duty to make sure that the patient understands that all insured services are available without any charge to the patient. Non-hospital facilities must provide an itemized list of services billed to the patient to ensure clarity between insured and billable non-insured services. A Patient Information Sheet on cataract surgery is provided in Annex B of the above policy. Non-hospital designated facilities must post the Patient Information Sheet in visible areas for public viewing. They must also provide a copy of this information sheet to all patients who are receiving cataract surgery in a non-hospital designated facility for patient signature.
The Lieutenant-Governor in Council has the authority to suspend or cancel a non-hospital facility's designation status if the non-hospital facility fails to comply with the above policy.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ NIL
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ NIL
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges >$ NIL
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
Extra billing is not permitted, as per the Province of Prince Edward Island's Health Services Payment Act.
PEI's Hospital and Diagnostic Services Insurance Act (HDSIA) does not explicitly prohibit user charges for insured health services. However, there are a number of sections in the HDSIA Regulations that infer that user charges would be prohibited, as described below.
Section 1.1(l): "insured services" means, subject to subsection (2), the in-patient and out-patient hospital services available to an entitled person without charge, as determined by the Minister but does not include any services to which a person is entitled, and for which a person is eligible, under any law mentioned in Schedule C"
Section 6.1: An approved hospital shall make a direct charge in respect of the patient who is an entitled person for the difference between the per diem cost of providing insured services and the hospital charges approved by the Minister for private or semi-private accommodation and for any other services which are not insured services requested by or on behalf of the patient.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
Please use as much space as needed below.
Health PEI administers a system of internal controls when reviewing physician billings, and investigates irregularities in billing. Physicians are subject to internal audit of billing practices to ensure all amounts billed to Health PEI are appropriate.
Annual financial results for Health PEI are reviewed to identify irregularities and significant variances. This includes a review of revenues to identify any new revenue items (ie. user charges). These revenues are also subject to review by the Auditor General.
The Province of Prince Edward Island offers several avenues for patients and the general public to provide feedback and complaints, including a "Compliments and Complaints" link on the Health PEI website. The Minister of Health and Wellness, the CEO of Health PEI and staff can also be contacted by anyone who may have been subject to any extra billing or user charges. Health PEI follows up on any complaints, including those around billing practices.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
Please use as much space needed bellow or add extra pages as necessary.
Health PEI conducts physician billing audits on the appropriateness of amounts billed to Health PEI by physicians for insured services. Health PEI does not have access to physicians’ financial records to determine whether any insured services were billed separately to individuals or third parties other than Health PEI. No incidences of extra billing or user charges were noted during these audits.
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
Please use as much space as needed below.
Potential new revenue sources for Health PEI are subject to evaluation and approval by Finance and executive leadership, where user charges for insured services would be noted and rejected.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 0
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 0
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below.
With respect to extra-billing, Nova Scotia's Health Services and Insurance Act (HSIA) provides:
29 (1) Where a provider renders an insured professional service to a resident, the provider shall be entitled to receive in respect of that service only the fee or compensation provided in the tariff of fees or other system of payment established pursuant to Section 13.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
Please use as much space as needed below.
Nova Scotia relies on a complaints-based system where concerns are brought to the attention of the Minister on a case by case basis. Complaints are directed to the Department of Health and Wellness via telephone or email; are received by Medavie Blue Cross and then directed to the Department; or are directed to the College of Physicians and Surgeons of Nova Scotia. All complaints are investigated and addressed.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
Please use as much space needed bellow or add extra pages as necessary.
There were no investigations in the 2019-2020 fiscal year. Nova Scotia has no legislative authority to audit private clinics.
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
Please use as much space as needed below.
Under the HSIA, a breach of provision 29 (1) could constitute an offense subject to criminal prosecution:
35 (1) Any person who violates this Act or the regulations or wilfully makes a false statement in any report or form required to enable a payment to be made under the Hospital Insurance Plan, the Insured Prescription Drug Plan or the M.S.I Plan is guilty of an offence and liable on summary conviction to a fine of not more than ten thousand dollars for a first offence and for a subsequent offence to a fine of not more than twenty thousand dollars.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 0
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 0
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
New Brunswick's Medical Services Payment Act and its Regulations (MSPA) describe mechanisms creating a health system which is Publicly Administered, Comprehensive, Universally available to its beneficiaries, Portable, and Accessible. It defines who may receive or provide an entitled service and how fee schedules are determined and prohibits extra-billing or user charges for any such service remunerated through the Medicare Branch.
Some providers may choose to practise outside the MSPA. The MSPA establishes a wall between the publicly funded system (which meets the principles outlined above) and entrepreneurial private business, prohibiting any practitioner payments which exceed the established fee schedules, and payments to private hospitals. It also establishes a private practitioner's duty to inform prospective patients.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
Please use as much space as needed below.
New Brunswick uses a robust "comment based" approach to identifying individual citizens’ concerns on a wide range of health issues. In a typical month in the 2019-2020 fiscal year the Department of Health received, logged, and responded to 100-150 concerns from individual New Brunswickers on issues including access to primary or specialized care, pharmaceutical approvals, access to services in a citizen's language of choice, wait times for specific services, the structure of specific programs, etc. The Department's web page provides several mechanisms to make such comments, including mailing addresses, e-mail addresses, telephone numbers, and a web-based message service
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
Please use as much space as needed bellow.
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
Please use as much space as needed below.
New Brunswick's Medical Services Payment Act and its Regulations (MSPA) describe mechanisms creating a health system which is Publicly Administered, Comprehensive, Universally available to its beneficiaries, Portable, and Accessible. It defines who may receive or provide an entitled service and how fee schedules are determined and prohibits extra-billing or user charges for any such service remunerated through the Medicare Branch.
Some providers may choose to practise outside the MSPA. The MSPA establishes a wall between the publicly funded system (which meets the principles outlined above) and entrepreneurial private business, prohibiting any practitioner payments which exceed the established fee schedules, and payments to private hospitals. It also establishes a private practitioner's duty to inform prospective patients
International and Intergovernmental Affairs Directorate
By Email
Quebec, December 17, 2021
Gigi Mandy Executive Director Canada Health Act Division Strategic Policy Branch Health Canada Brooke Claxton Building, 8th floor 70 Columbine Driveway, Tunney's Pasture Postal Locator 0908C Ottawa, Ontario K1 A 0K9
Dear Ms. Mandy,
This letter is in follow-up to the letter sent to the Deputy Minister of Health and Social Services, Dominique Savoie, on October 13. The letter requested the total amount of extra-billing and user charges for the year 2019-2020.
In Quebec, the health insurance plan is regulated by the Health Insurance Act. However, this Act does not allow user fees to be imposed. It also prohibits any person from demanding or receiving any payment from a person for incidental fees related to an insured service, except in cases prescribed by regulation or provided for in an agreement and the conditions mentioned therein.
In order to provide further clarification about this prohibition, the Government of Quebec has approved a draft regulation expressly prohibiting any fees related to services insured by Quebec's health insurance plan as well as all accessory fees provided for in compensation agreements with physicians. This regulation has been in effect since January 2017. Of course, in the event of actions, whatever they may be, that are contrary to Quebec's statutes and regulations, the Régie de l'assurance maladie du Québec will take the appropriate measures to rectify the situation.
As you are no doubt aware, health and social services are within the exclusive jurisdiction of the provinces. As such, Quebec intends to remain responsible for the management, organization and planning of care and services on its territory.
Moreover, the Government of Quebec is accountable to the National Assembly and the people of Quebec with respect to how the Quebec healthcare system is run. Thus, Quebec will continue to fulfill this responsibility to Quebec's citizens, who are the ultimate arbiters as to the quality and accessibility of the services provided to them by our healthcare system.
For your information, you may consult the 2019-2020 annual management report of the Ministère de la Santé et des Services sociaux (MSSS), tabled in the National Assembly, which provides an accounting of how Quebec manages its healthcare system and which you will find on the MSSS website under the tab "Publications."
Sincerely,
Valérie Fontaine, Director Ref/no.: 21-MS-08896
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ NIL
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ NIL
Amount determined by Health Canada to be non-compliant: $6,560
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 6,560
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
The Ontario Health Insurance Plan (OHIP) and all insured services are set out under the Health Insurance Act (HIA) and Regulations.
In Ontario, a combination of two pieces of legislation prohibit any person or entity from charging for all or part of an OHIP-insured service rendered to an insured person (i.e. EBUC, including illegal facility fees). These statutes are as follows:
The Commitment to the Future of Medicare Act (CFMA) prohibits any person or entity from charging unauthorized payments for all or part of an OHIP-insured service rendered to an insured person. Such charges include extra-billing (i.e. charges to insured persons for insured physician and dental-surgical services) and user charges (i.e. charges to insured persons for non-physician/dental-surgical services provided in conjunction with insured services at a hospital).
The CFMA also prohibits providers and other entities from providing preferred access to an insured service conditional on the payment of a fee, which is called queue-jumping, and from making the provision of an insured service conditional on paying a block fee for uninsured services.
The CFMA applies regardless of the type of facility or setting in which a service is rendered.
The Independent Health Facilities Act (IHFA) prohibits any person from charging facility fees unless in accordance with the Act (e.g. facility fees are only payable by the Minister or Ontario Health, only in licensed facilities, etc.). A facility fee is a charge, fee or payment in respect of a service or operating cost that supports, assists or is a necessary adjunct to an OHIP-insured service, and is not part of the insured service.
Regardless of whether an insured service is provided in a licensed IHF or any other private, community-based setting, a charge or payment in respect of a service or operating cost that supports, assists and/or is a necessary adjunct to an insured service, but is not part of the insured service, that is not in compliance with the IHFA is an illegal facility fee.
Through a dedicated program (CFMA Program), the Ontario Ministry of Health (the ministry) reviews all possible cases of EBUC brought to its attention. Charging facility fees contrary to the IHFA may also have implications under the CFMA, and therefore, the ministry's CFMA Program also reviews allegations of illegal facility fees under the IHFA in conjunction with the ministry's IHF program.
If, as a result of a review, it is determined that a patient has paid an unauthorized payment (i.e. extra-billing) and/or user charge, the ministry ensures that the full amount is reimbursed to the patient.
b) A summary of any extra-billing and user charges investigations during the fiscal year including:
Please use as much space needed bellow or add extra pages as necessary.
As noted above, the ministry reviews all possible instances of EBUC that come to its attention. Patient complaints regarding possible EBUC and questions from the public are received mostly via a dedicated tollfree number and email address. Information regarding possible EBUC arises primarily from patient complaints; however, the ministry may also review possible violations that are brought to its attention by other sources such as Health Canada, MPPs, the media, advertisements, etc.
All inquiries from patients and other sources regarding out-of-pocket charges for health care services are responded to and are assessed to determine whether or not a CFMA review is opened (i.e., was the service charged for clearly uninsured or is further review required?). If it is determined that EBUC may have occurred, according to CFMA Program policy, patients are asked to complete a CFMA Program form for the ministry to open a review.
As part of a review, the ministry requests relevant records and/or information from providers under authority of the CFMA (e.g. medical and/or hospital/facility records related to the service the patient was charged for, copies of all invoices and receipts, a breakdown of any patient charges, etc.). Once the requested information has been received, it is reviewed by CFMA Program staff in order to determine whether a specific service provided to a patient was insured. In almost all cases, ministry medical advisors are consulted for assistance in interpreting medical records. Staff may also consult with other areas of the ministry.
The ministry can and does review possible EBUC on a proactive basis (i.e. without receiving a patient specific complaint). As noted above, reviews often require examinations of specific patient records to determine whether a specific service provided to a patient was insured, and therefore, without a specific patient complaint, the ministry primarily undertakes these reviews for the purposes of provider education, seeking information regarding general practices and policies to ensure their compliance with Ontario legislation.
If the ministry finds through a CFMA review that a patient has paid an illegal extra-billing fee or user charge, the ministry ensures that the full amount is reimbursed to the patient.
The CFMA contains provincial offence provisions, where individuals and corporations in violation of the CFMA are subject to fines and/or a restitution order if convicted of an offence under the CFMA. Therefore, when a CFMA review identifies possible intentional CFMA violations, the matter is referred to the Ontario Provincial Police Health Fraud Investigation Unit.
c) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
Please use as much space as needed below.
In FY 2019-2020, the ministry conducted 61 reviews of potential EBUC under the CFMA as follows:
Of the 61 reviews, 38 reviews resulted in a determination that a patient was not charged for all or part of an insured services as per Ontario legislation and regulation:
21 of the 61 reviews resulted in a determination that a patient was charged for an insured service contrary to Ontario legislation, and each patient was reimbursed in full. A breakdown of these reviews is as follows:
Therefore, Ontario is reporting $nil for extra-billing charges for FY 2019-2020.
In addition to the above-noted reviews, Ontario also undertook two separate reviews at the request of Health Canada, which advised Ontario of its concerns that two private abortion clinics may be charging patients mandatory fees ("clinic" or "block" fees) in order to access insured surgical abortion services contrary to the CHA. The ministry promptly opened reviews into these two clinics and determined that each clinics’ block fee is in compliance with Ontario legislation as they do not include charges for insured services and do not constitute an illegal facility fee. However, given Health Canada's decision that since the majority of patients for whom records were received as part of these reviews (101 out of 120 patients) paid a block fee, Ontario is deferring to Health Canada's decision and calculation of a user fee in the amount of $6,560.00 for FY 2019-2020. Please note that there is no mechanism under the CFMA that would allow the ministry to reimburse patients for payments for services that, in the General Manager's opinion, are uninsured services.
In accordance with ministry direction, the clinics updated their patient materials, including their websites to make it clear that there are no fees for insured abortion services.
Note: The total amount charged was developed using calculations provided by Health Canada on February 18, 2021.
Health Canada has also expressed concerns with respect to a third private abortion clinic which is currently under review by the ministry.
The ministry would like to reiterate that, at the request of Health Canada and/or other stakeholders, the ministry has undertaken several proactive reviews of private abortion clinics not currently funded under the IHFA, and specifically, that all non-IHF clinics known to the ministry have been reviewed at least once in the past four years, and four out of five have been reviewed twice in that timeframe. Additionally, the ministry has received very few complaints directly from patients who have been charged in association with insured abortion services in Ontario.
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
Please use as much space as needed below.
Through a dedicated program (CFMA Program), the Ontario Ministry of Health (the ministry) reviews all possible cases of EBUC brought to its attention.
The ministry takes steps to prevent EBUC by maintaining a webpage (http://www.health.gov.on.ca/en/public/programs/ohip/cfma.aspx ) which provides public information regarding the CFMA, including what is prohibited under the Act (i.e., extra-billing, queue-jumping, illegal block fees), how to determine if they have been charged for an insured service or for access to an insured service, and how to contact the ministry via a dedicated toll-free number and email address in order to open an review or ask a question regarding a possible CFMA violation.
The ministry also regularly undertakes proactive CFMA reviews that are not tied to a specific patient complaint. In many cases, these investigations are done for the purposes of provider education, in order for the ministry to communicate the provider's obligations under the Canada Health Act (CHA) and CFMA, and to ensure that their billing practices are amended as appropriate to comply with Ontario legislation.
The ministry has also in the past undertaken patient education initiatives to increase awareness among members of the general public about the protections under the CFMA and to encourage filing of valid complaints to the CFMA program so that reviews can be initiated.
In rare but serious cases where the person or entity fails to comply with a CFMA review without just cause (e.g., if a provider or entity fails to provide the ministry with requested information relevant to the determination of whether or not EBUC has occurred), the Act authorizes the ministry to suspend all OHIP payments to the person or entity pending receipt of the requested information.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 0
N.B Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 0
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
Please use as much space as needed below.
In the event that a Manitoba resident feels that they have been inappropriately charged for a service that is insured under the provincial health insurance plan (i.e., a potential incidence of extra-billing or a user charge), or of a report or allegation of extra-billing or user charges, the department will investigate the complaint, report or allegation appropriately. Residents may contact Manitoba Health and Seniors Care (MHSC) to report such occurrences through any of the contact coordinates listed on our website, including our Audit and Investigation Fraud Line.
Inquiries are made by the Insured Benefits Branch of MHSC into the specifics of any fee(s) charged to assess whether the service provided was an insured service, and any required further action.
Generally, in the event that there has been a fee charged that could be considered an instance of extra-billing or a user charge, contact from MHSC to the medical service provider advising that the provider must reimburse the patient and submit a claim to MHSC is sufficient to address the concern. Further incidents on the part of the same service provider could result in an investigation by MHSC's Audit and Investigation Unit. Concerns regarding the professional conduct of medical service providers would be referred to the appropriate regulatory agency.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
Please use as much space needed bellow or add extra pages as necessary.
There were no formal investigations conducted in 2019-2020 on the basis of complaints from residents of Manitoba. There were no confirmed cases of extra-billing or user charges.
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
Please use as much space as needed below.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 0
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 0
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
The Saskatchewan Medical Care Insurance Act precludes physicians/dentists who provide insured services from charging patients more than the amount paid for that service under the Act, unless the physician/dentist has opted out entirely from receiving payments under the Act. Notice must also be given to the province where a physician/dentist opts out. No notices have been received for the reporting period.
The Saskatchewan Medical Care Insurance Act includes provisions which indicate that any amount that a physician who provides insured services requires a beneficiary to pay or to have paid as a condition of receiving an insured service which exceeds the amount to be paid for that service under the Act, is considered to be a charge.
The Health Facilities Licensing Act precludes any licensee from charging or permitting any other person to charge any fee to any beneficiary for any insured health service performed at the health facility.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
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With regards to extra-billing, compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as complaints from members of the public.
When requests are made by a beneficiary seeking reimbursement of monies paid directly to a physician for insured physician services that are extra-billing charges, correspondence is sent to the beneficiary (copying the physician) advising them of Section 18 (1.1) of the Saskatchewan Medical Care Insurance Payment Act that a physician must accept the negotiated rate as payment in full for insured services provided to a beneficiary. Once the physician has received payment from Medical Services for the eligible service(s), reimbursement for any difference in the amount charged by the practitioner and the amount paid by Medical Services should be collected directly from the practitioner. If a further complaint is made, the beneficiary is directed to address complaints to the Saskatchewan College of Physicians and Surgeons.
Persons who have a complaint of an extra-billing charge may raise the concern with the College of Physicians and Surgeons of Saskatchewan. Section 7.1 (Code of Ethics) in the College's bylaws notes the following:
With regards to user charges, compliance is monitored through consultations with the provincial health authority, physicians and dentists, as well as complaints from members of the public.
Persons who have a complaint of user charges may raise the concern with the College of Physicians and Surgeons of Saskatchewan. Section 7.1 (Code of Ethics) in the College's bylaws notes the following:
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
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For the 2019-2020 fiscal year Saskatchewan is reporting $0 in extra-billing. Saskatchewan has no information that extra-billing charges have been levied during the reporting period. For the 2019-2020 fiscal year Saskatchewan is reporting $0 in User Charges. Saskatchewan has no information that user charges have been levied during the reporting period. Saskatchewan is not aware of charges being levied for insured services provided in a hospital. Nor is Saskatchewan aware of any additional charges for insured services being levied in a physician clinic as defined in the federal private clinics policy.
Please note that MRI and CT scans performed under The Patient Choice Medical Imaging Act (PCMIA) are not reported as these services are non-insured services under The Saskatchewan Medical Care Insurance Act, and are authorized under the PCMIA and The Medical Imaging Facilities Licensing Regulations.
The private-pay MRI/CT service with its unique two-for-one provision gives patients more options in accessing MRI/CT services and has added capacity to the publicly-funded system at no extra cost to the health system or the patient on the public waitlist receiving the reciprocal scan. Along with increases in public capacity, through expanded hospital volumes, new MRI and CT scanners, and increased volumes in publicly funded contracts, these privately funded scans and second scans are assisting in the management of MRI/CT wait times. They increase overall system capacity for less complex cases, thereby freeing up capacity in hospitals to perform more complex exams
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
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The Saskatchewan Medical Care Insurance Act and the Health Facilities Licensing Act stipulate monetary penalties for individuals guilty of contravening the Act(s), including extra-billing and user charges of insured health services.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 0
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 0
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
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Alberta Health has reviewed the Canada Health Act form Financial Statement of Actual Amounts of Extra-Billing and User Charges for the Period April 1, 2019 to March 31, 2020 and reporting guidelines. Alberta Health uses the following processes to determine and investigate extra billing and user charges (EBUC):
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
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d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
Please use as much space as needed below.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Based on Health Canada Methodology (See Appendix A) $13,275,728
Charges Based on Unresolved Patient Complaints (See Appendix B) $95
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 0
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 13,275,823
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
The Medicare Protection Act (MPA) sets out the requirements for insured medical services (also known as benefits) provided to residents of British Columbia (BC). The MPA establishes rules regarding billing for services provided by physicians who are enrolled with the Medical Services Plan (MSP). The MPA also prohibits anyone from charging patients for "materials, consultations, procedures, use of an office, clinic, or for any other matters that relate to the rendering of a benefit" unless specifically permitted by the Medical Services Commission (MSC).
The Canada Health Act (CHA) establishes criteria that provinces must meet with respect to "insured health services" (which include any medically required services of hospitals and medical practitioners) in order to receive full federal transfer payments. The CHA explicitly prohibits user fees and extra-billing of patients for insured services and requires the federal government to deduct an amount equal to such charges from transfer payments to a province involved.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
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Beneficiary and Diagnostic Services Branch: The Beneficiary and Diagnostic Services Branch of the BC Ministry of Health (the Ministry) receives correspondence from beneficiaries reporting instances of potential extra-billing and user charges. Ministry staff review and respond to all correspondence, including the use of medical consultants to review medical records. In cases where there is potential extra-billing, letters are sent out to the clinics or individual physicians requesting clarification for any charges as well as reimbursement to beneficiaries in case of erroneous billing, extra-billing or user charges.
Audit and Investigation Branch, Billing Integrity Program: In 2017, Health Canada and the Ministry agreed upon a methodology to determine the extent and nature of patient extra-billing in BC, outlined in a Terms of Reference and Letter of Agreement. Since this agreement, the Ministry has completed ten audits of private surgical clinics, including Cambie Surgeries Corporation. The results of these audits were shared with Health Canada in accordance with the signed agreement.
In 2018-2019 further planned audits were put on hold to ensure the Ministry complied with the November 23, 2018, BC Supreme Court injunction prohibiting the enforcement of the extra-billing provisions (s. 17, 18, and 45 of the MPA). Audits resumed in late 2020 with plans to complete the remaining five on-site audits. Three of five on-sites audits have been conducted, with the remaining two scheduled for early 2022.
The Ministry has an established audit unit that is responsible for the ongoing audit of existing private surgical centers. By 2022 the audit unit is intending to complete the final 2 private surgery audits bringing the total completed to 12, including Cambie.
The Ministry will provide the final audit reports for individual clinics and/or providers to Health Canada subject to any redactions required to comply with the Freedom of Information and Personal Privacy Act. The Ministry is working through concerns and legalities around posting summarized versions of audit reports online. The Ministry will be adding communication resources for this work and recruitment to staff these positions will be undertaken in the short term. Their first order of priority will be to make sure this is completed and posted in a timely manner.
Subject to clarification from the Court, the Ministry is committed to full transparency and will continue to work with Health Canada in reviewing audit findings as the work is completed. Monthly conference calls to discuss extra-billing and other pertinent matters including audit findings have been re-established.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
Three complaints where extra-billing was determined to have likely occurred.
Four complaints received where it was determined no extra-billing occurred (e.g. service was not a benefit).
One complaint where the issue was an ethical/clinical practice issue and not a billing issue (patient was referred to the College of Physicians and Surgeons of BC).
These were patient triggered investigations.
Of the three cases, dollar values were $2,764.42, $500.00, and $95.00 respectively. See Appendix B for a breakdown of each case.
$3,264.42 was reimbursed to patients
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d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
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In October 2018, BC brought the remaining provisions of the Medicare Protection Amendment Act Bill 92 (2003) into force to address the Province's ability to respond to extra-billing and to bring BC in compliance with the CHA.
The key changes to the MPA resulting from Bill 92 include:
Currently, the regional health authorities (HA) monitor surgical contracts for compliance with all provisions of the MPA. Contracts require a signed compliance statement by physicians which acknowledges the termination provisions in the contract between the HA and their clinic pertaining to extra-billing. These provisions apply to the physician's service under contract (which are insured services) as well as services undertaken by the physician in a clinic outside of the contract (the latter would be insured services provided at the clinic). Since implementation of the compliance statements in September 2018, the HAs have not terminated any contracts with private surgical clinics over performance or compliance issues.
The Ministry works closely with the MSC to ensure that operational processes are designed to protect patients from extra-billing. The Ministry processes patient complaints and investigates allegations of extra-billing to determine whether extra-billing has taken place. Where possible, throughout the investigation, the Ministry seeks to resolve the complaint by communication and education with the physician.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 0
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 0
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
There are no user fees or co-insurance charges for Insured Health Service under the Yukon Health Care Insurance Plan or the Yukon Hospital Insurance Plan. All services are provided on a uniform basis and are not impeded by financial or other barriers. There is no extra-billing in Yukon for any services covered by the Plans.
The Yukon Health Care Insurance Plan Act defines Insured Health Services as:
"those physician services, surgical-dental services, and other health services including the supply of drugs, medical and dental supplies, prostheses..."
In FY 2019-2020 Yukon did not have any private for-profit health care facilities delivering insured health services. Information submitted excludes government operated continuing car facilities in Yukon.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
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Regular audits of physician claims along with reactive investigations triggered by client and/or other physician complaints. Annual audit of the programs by the Auditor General.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
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d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
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The preamble to the Yukon Physician Fee Guide contains the following:
"No fee above or in addition to the Payment Schedule may be charged toe either YHCIP (Yukon Health Care Insurance Plan) or to the patient for insured health services.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 0
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 0
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
There are two pieces of legislation in the Northwest Territories which prohibit extra billing and user charges. Section 14(1) of the Northwest Territories Medical Care Act states that: "No medical practitioner shall charge to or collect from an insured person a fee in excess of the benefit in respect of the insured service, unless the medical practitioner has made an election that is still in effect." In addition, section 8(2) of the Hospital Insurance Regulations under the Hospital Insurance and Health and Social Services Administration Act also states that: "The rate payable to a hospital or federal hospital that is situated in a province or territory participating under the federal Act (i.e. Canada Health Act) shall not exceed the rate established for the hospital by that province or territory, less the authorized charge." Therefore, residents of the NWT are protected from extra billing and charges when receiving insured services both within the territory, and when receiving insured services outside the territory under a reciprocal billing agreement.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
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Medical Care Act 8. (1) (2) (3) (4) 8.(1) The Director may reassess an account for insured services submitted by a medical practitioner, where, as a result of an inspection under section 7, it appears to the Director that(a) all or part of the insured services were not in fact rendered;(b) all or part of the insured services were not medically necessary;(c) all or part of the insured services were not provided in accordance with accepted professional standards and practice; or(d) the nature of the insured services is misrepresented.
(2) Where the Director makes a reassessment under subsection (1), the Director may make any appropriate adjustment in the amount paid to the medical practitioner in respect of the insured services.
(3) If the amount paid to a medical practitioner for insured services was in excess of the benefit payable under the adjustment referred to in subsection(2), the difference between the amount paid and the adjusted amount constitutes a debt to the Government of the Northwest Territories and the Director may recover the amount from the medical practitioner(a) by withholding from benefits payable to the medical practitioner an amount equivalent to the difference between the amount paid and the adjusted amount;(b) by civil action; or(c) pursuant to an agreement between the Director and the medical practitioner providing for the payment of the amount.
(4) If the amount paid to a medical practitioner for insured services was less than the benefit payable under the adjustment referred to in subsection (2), the Director shall pay to the medical practitioner an amount equal to the difference between the amount paid and the adjusted amount.
The NWT has a "complaint-based" system in place, and takes steps to respond to concerns and improve care and services for NWT residents. When a resident has a concern or issue with the care they have received they are first encouraged to speak with their local health provider. If the issue is not resolved they are encouraged to contact their designated Patient Representative to help address the issue and file a formal complaint.
The Medical Care Act includes a provision to allow the Minister of Health and Social Services (the Minister) to establish a Benefits Appeal Committee that could address any matter referred to it by the Minister, including complaints where a physician engaged in extra-billing and charged user fees. At present, there has been no need to establish this committee, because almost all physicians are compensated through contractual agreements with the Government of the NWT.
No audits completed. Mostly salaried physicians All but two physicians in the NWT are on contract with the NT Health Authority and do not bill fee for service. The two NWT Fee for Service Physicians and all visiting specialist use the services of local NWT billing clerks who bill the appropriate fees according to the NWT fee tariff.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
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d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
Please use as much space as needed below.
Mostly salaried physicians All but two physicians in the NWT are on contract with the NT Health Authority and do not bill fee for service. The two NWT Fee for Service Physicians and all visiting specialist use the services of local NWT billing clerks who bill the appropriate fees according to the NWT fee tariff.
CANADA HEALTH ACT
FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES
FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020
Extra-billing is defined as a charge by an enrolled physician or dentist to an insured person for an insured service in addition to the amount paid by the provincial/territorial health insurance plan.
Amount of extra-billing levied by enrolled physicians and dentists for insured health services: $ 0.00
A user charge is defined as any charge for an insured health service, other than extra-billing. This includes any charge levied for insured hospital services, or any non-physician related services provided in conjunction with an insured physician service at a non-hospital facility (e.g., private clinic or private practice).
Amount of user charges levied for insured services: $ 0.00
N.B. Charges may be levied for accommodation and meal costs related to a patient who, in the opinion of the attending physician, is a permanent resident in a hospital or other chronic care institution as per the limitation of Section 19 (2). Charges related to this limitation should not be included in the financial statement.
Total for extra-billing and user charges $ 0.00
The following information should be included in the description of the method used to determine the amounts of extra-billing and user charges (EBUC) reported, including if a NIL amount is submitted:
a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees).
Please use as much space as needed below.
Nunavut utilizes physicians under contractual arrangements and does not bill fee for service. As such, there are no extra-billing fees to report. NIL REPORT.
Nunavut does not currently charge user fees at any public health care facility. NIL REPORT.
b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources).
Please use as much space as needed below.
N/A- See above.
c) A summary of any extra-billing and user charges investigations during the fiscal year including:
Please use as much space needed bellow or add extra pages as necessary.
N/A- See above.
d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation).
Please use as much space as needed below.
N/A- See above.
There are three 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 Health Ministers to their provincial and territorial counterparts.
[Following is the text of the letter sent on June 18, 1985, to all provincial and territorial Ministers of Health by the Honourable Jake Epp, federal Minister of Health and Welfare. (Note: Minister Epp sent the French equivalent of this letter to Quebec on July 15, 1985.)]
June 18, 1985
OTTAWA, K1A 0K9
Dear Minister:
Having consulted with all provincial and territorial Ministers of Health over the past several months, both individually and at the meeting in Winnipeg on May 16 and 17, I would like to confirm for you my intentions regarding the interpretation and implementation of the Canada Health Act. I would particularly appreciate if you could provide me with a written indication of your views on the attached proposals for regulations in order that I may act to have these officially put in place as soon as conveniently possible. Also, I will write to you further with regard to the material I will need to prepare the required annual report to Parliament.
As indicated at our meeting in Winnipeg, I intend to honour and respect provincial jurisdiction and authority in matters pertaining to health and the provision of health care services. I am persuaded, by conviction and experience, that more can be achieved through harmony and collaboration than through discord and confrontation.
With regard to the Canada Health Act, I can only conclude from our discussions that we together share a public trust and are mutually and equally committed to the maintenance and improvement of a universal, comprehensive, accessible and portable health insurance system, operated under public auspices for the benefit of all residents of Canada.
Our discussions have reinforced my belief that you require sufficient flexibility and administrative versatility to operate and administer your health care insurance plans. You know far better than I ever can, the needs and priorities of your residents, in light of geographic and economic considerations. Moreover, it is essential that provinces have the freedom to exercise their primary responsibility for the provision of personal health care services.
At the same time, I have come away from our discussions sensing a desire to sustain a positive federal involvement and role—both financial and otherwise—to support and assist provinces in their efforts dedicated to the fundamental objectives of the health care system: protecting, promoting and restoring the physical and mental well-being of Canadians. As a group, provincial/territorial Health Ministers accept a co-operative partnership with the federal government based primarily on the contributions it authorizes for purposes of providing insured and extended health care services.
I might also say that the Canada Health Act does not respond to challenges facing the health care system. I look forward to working collaboratively with you as we address challenges such as rapidly advancing medical technology and an aging population and strive to develop health promotion strategies and health care delivery alternatives.
Returning to the immediate challenge of implementing the Canada Health Act, I want to set forth some reasonably comprehensive statements of federal policy intent, beginning with each of the criteria contained in the Act.
Public Administration
This criterion is generally accepted. The intent is that the provincial health care insurance plans be administered by a public authority, accountable to the provincial government for decision-making on benefit levels and services, and whose records and accounts are publicly audited.
Comprehensiveness
The intent of the Canada Health Act is neither to expand nor contract the range of insured services covered under previous federal legislation. The range of insured services encompasses medically necessary hospital care, physician services and surgical-dental services which require a hospital for their proper performance. Hospital plans are expected to cover in-patient and out-patient hospital services associated with the provision of acute, rehabilitative and chronic care. As regards physician services, the range of insured services generally encompasses medically required services rendered by licensed medical practitioners as well as surgical-dental procedures that require a hospital for proper performance. Services rendered by other health care practitioners, except those required to provide necessary hospital services, are not subject to the Act's criteria.
Within these broad parameters, provinces, along with medical professionals, have the prerogative and responsibility for interpreting what physician services are medically necessary. As well, provinces determine which hospitals and hospital services are required to provide acute, rehabilitative or chronic care.
Universality
The intent of the Canada Health Act is to ensure that all bonafide residents of all provinces be entitled to coverage and to the benefits under one of the twelve provincial/territorial health care insurance plans. However, eligible residents do have the option not to participate under a provincial plan should they elect to do so.
The Agreement on Eligibility and Portability provides some helpful guidelines with respect to the determination of residency status and arrangements for obtaining and maintaining coverage. Its provisions are compatible with the Canada Health Act.
I want to say a few words about premiums. Unquestionably, provinces have the right to levy taxes and the Canada Health Act does not infringe upon that right. A premium scheme per se is not precluded by the Act, provided that the provincial health care insurance plan is operated and administered in a manner that does not deny coverage or preclude access to necessary hospital and physician services to bonafide residents of a province. Administrative arrangements should be such that residents are not precluded from or do not forego coverage by reason of an inability to pay premiums.
I am acutely aware of problems faced by some provinces in regard to tourists and visitors who may require health services while travelling in Canada. I will be undertaking a review of the current practices and procedures with my Cabinet colleagues, the Minister of External Affairs, and the Minister of Employment and Immigration, to ensure all reasonable means are taken to inform prospective visitors to Canada of the need to protect themselves with adequate health insurance coverage before entering the country.
In summary, I believe all of us as Ministers of Health are committed to the objective of ensuring that all duly qualified residents of a province obtain and retain entitlement to insured health services on uniform terms and conditions.
Portability
The intent of the portability provisions of the Canada Health Act is to provide insured persons continuing protection under their provincial health care insurance plan when they are temporarily absent from their province of residence or when moving from province to province. While temporarily in another province of Canada, bonafide residents should not be subject to out-of-pocket costs or charges for necessary hospital and physician services. Providers should be assured of reasonable levels of payment in respect of the cost of those services.
Insofar as insured services received while outside of Canada are concerned, the intent is to assure reasonable indemnification in respect of the cost of necessary emergency hospital or physician services or for referred services not available in a province or in neighbouring provinces. Generally speaking, payment formulae tied to what would have been paid for similar services in a province would be acceptable for purposes of the Canada Health Act.
In my discussions with provincial/territorial Ministers, I detected a desire to achieve these portability objectives and to minimize the difficulties that Canadians may encounter when moving or travelling about in Canada. In order that Canadians may maintain their health insurance coverage and obtain benefits or services without undue impediment, I believe that all provincial/territorial Health Ministers are interested in seeing these services provided more efficiently and economically.
Significant progress has been made over the past few years by way of reciprocal arrangements which contribute to the achievement of the in-Canada portability objectives of the Canada Health Act. These arrangements do not interfere with the rights and prerogatives of provinces to determine and provide the coverage for services rendered in another province. Likewise, they do not deter provinces from exercising reasonable controls through prior approval mechanisms for elective procedures. I recognize that work remains to be done respecting interprovincial payment arrangements to achieve this objective, especially as it pertains to physician services.
I appreciate that all difficulties cannot be resolved overnight and that provincial plans will require sufficient time to meet the objective of ensuring no direct charges to patients for necessary hospital and physician services provided in other provinces.
For necessary services provided out-of-Canada, I am confident that we can establish acceptable standards of indemnification for essential physician and hospital services. The legislation does not define a particular formula and I would be pleased to have your views.
In order that our efforts can progress in a coordinated manner, I would propose that the Federal-Provincial Advisory Committee on Institutional and Medical Services be charged with examining various options and recommending arrangements to achieve the objectives within one year.
Reasonable Accessibility
The Act is fairly clear with respect to certain aspects of accessibility. The Act seeks to discourage all point-of-service charges for insured services provided to insured persons and to prevent adverse discrimination against any population group with respect to charges for, or necessary use of, insured services. At the same time, the Act accents a partnership between the providers of insured services and provincial plans, requiring that provincial plans have in place reasonable systems of payment or compensation for their medical practitioners in order to ensure reasonable access to users. I want to emphasize my intention to respect provincial prerogatives regarding the organization, licensing, supply, distribution of health manpower, as well as the resource allocation and priorities for health services. I want to assure you that the reasonable access provision will not be used to intervene or interfere directly in matters such as the physical and geographic availability of services or provincial governance of the institutions and professions that provide insured services. Inevitably, major issues or concerns regarding access to health care services will come to my attention. I want to assure you that my Ministry will work through and with provincial/territorial Ministers in addressing such matters.
My aim in communicating my intentions with respect to the criteria in the Canada Health Act is to allow us to work together in developing our national health insurance scheme. Through continuing dialogue, open and willing exchange of information and mutually understood rules of the road, I believe that we can implement the Canada Health Act without acrimony and conflict. It is my preference that provincial/territorial Ministers themselves be given an opportunity to interpret and apply the criteria of the Canada Health Act to their respective health care insurance plans. At the same time, I believe that all provincial/territorial Health Ministers understand and respect my accountability to the Parliament of Canada, including an annual report on the operation of provincial health care insurance plans with regard to these fundamental criteria.
Conditions
This leads me to the conditions related to the recognition of federal contributions and to the provision of information, both of which may be specified in regulations. In these matters, I will be guided by the following principles:
to make as few regulations as possible and only if absolutely necessary;
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;
to employ consultation processes and mutually beneficial information exchanges as the preferred ways and means of implementing and administering the Canada Health Act;
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:
estimates and statements on extra-billing and user charges;
an annual provincial statement (perhaps in the form of a letter to me) to be submitted approximately six months after the completion of each fiscal year, describing the respective provincial health care insurance plan's operations as they relate to the criteria and conditions of the Canada Health Act.
Concerning Item 1 above, I propose to put in place on-going regulations that are identical in content to those that have been accepted for 1985-86. Draft regulations are attached as Annex I. To assist with the preparation of the "annual provincial statement" referred to in Item 2 above, I have developed the general guidelines attached as Annex II. Beyond these specific exchanges, I am confident that voluntary, mutually beneficial exchange of such subjects as Acts, regulations and program descriptions will continue.
One matter brought up in the course of our earlier meetings, is the question of whether estimates or deductions of user charges and extra-billing should be based on "amounts charged" or "amounts collected". The Act clearly states that deductions are to be based on amounts charged. However, with respect to user fees, certain provincial plans appear to pay these charges indirectly on behalf of certain individuals. Where a provincial plan demonstrates that it reimburses providers for amounts charged but not collected, say in respect of social assistance recipients or unpaid accounts, consideration will be given to adjusting estimates/deductions accordingly.
I want to emphasize that where a provincial plan does authorize user charges, the entire scheme must be consistent with the intent of the reasonable accessibility criterion as set forth [in this letter].
Regulations
Aside from the recognition and information regulations referred to above, the Act provides for regulations concerning hospital services exclusions and regulations defining extended health care services.
As you know, the Act provides that there must be consultation and agreement of each and every province with respect to such regulations. My consultations with you have brought to light few concerns with the attached draft set of Exclusions from Hospital Services Regulations.
Likewise, I did not sense concerns with proposals for regulations defining Extended Health Care Services. These help provide greater clarity for provinces to interpret and administer current plans and programs. They do not alter significantly or substantially those that have been in force for eight years under Part VI of the Federal Post-Secondary Education and Health Contributions Act (1977). It may well be, however, as we begin to examine the future challenges to health care that we should re-examine these definitions.
This letter strives to set out flexible, reasonable and clear ground rules to facilitate provincial, as much as federal, administration of the Canada Health Act. It encompasses many complex matters including criteria interpretations, federal policy concerning conditions and proposed regulations. I realize, of course, that a letter of this sort cannot cover every single matter of concern to every provincial Minister of Health. Continuing dialogue and communication are essential.
In conclusion, may I express my appreciation for your assistance in bringing about what I believe is a generally accepted concurrence of views in respect of interpretation and implementation. As I mentioned at the outset of this letter, I would appreciate an early written indication of your views on the proposals for regulations appended to this letter. It is my intention to write to you in the near future with regard to the voluntary information exchanges which we have discussed in relation to administering the Act and reporting to Parliament.
Yours truly, Jake Epp Attachments
[Following is the text of the letter sent on January 6, 1995, to all provincial and territorial Ministers of Health by the federal Minister of Health, the Honourable Diane Marleau.]
January 6, 1995
Dear Minister:
RE: Canada Health Act
The Canada Health Act has been in force now for just over a decade. The principles set out in the Act (public administration, comprehensiveness, universality, portability and accessibility) continue to enjoy the support of all provincial and territorial governments. This support is shared by the vast majority of Canadians. At a time when there is concern about the potential erosion of the publicly funded and publicly administered health care system, it is vital to safeguard these principles.
As was evident and a concern to many of us at the recent Halifax meeting, a trend toward divergent interpretations of the Act is developing. While I will deal with other issues at the end of this letter, my primary concern is with private clinics and facility fees. The issue of private clinics is not new to us as Ministers of Health; it formed an important part of our discussions in Halifax last year. For reasons I will set out below, I am convinced that the growth of a second tier of health care facilities providing medically necessary services that operate, totally or in large part, outside the publicly funded and publicly administered system, presents a serious threat to Canada's health care system.
Specifically, and most immediately, I believe the facility fees charged by private clinics for medically necessary services are a major problem which must be dealt with firmly. It is my position that such fees constitute user charges and, as such, contravene the principle of accessibility set out in the Canada Health Act.
While there is no definition of facility fees in federal or most provincial legislation, the term, generally speaking, refers to amounts charged for non-physician (or "hospital") services provided at clinics and not reimbursed by the province. Where these fees are charged for medically necessary services in clinics which receive funding for these services under a provincial health insurance plan, they constitute a financial barrier to access. As a result, they violate the user charge provision of the Act (section 19).
Facility fees are objectionable because they impede access to medically necessary services. Moreover, when clinics which receive public funds for medically necessary services also charge facility fees, people who can afford the fees are being directly subsidized by all other Canadians. This subsidization of two-tier health care is unacceptable.
The formal basis for my position on facility fees is twofold. The first is a matter of policy. In the context of contemporary health care delivery, an interpretation which permits facility fees for medically necessary services so long as the provincial health insurance plan covers physician fees runs counter to the spirit and intent of the Act. While the appropriate pro-vision of many physician services at one time required an overnight stay in a hospital, advances in medical technology and the trend toward providing medical services in more accessible settings has made it possible to offer a wide range of medical procedures on an out-patient basis or outside of full-service hospitals. The accessibility criterion in the Act, of which the user charge provision is just a specific example, was clearly intended to ensure that Canadian residents receive all medically necessary care without financial or other barriers and regardless of venue. It must continue to mean that as the nature of medical practice evolves.
Second, as a matter of legal interpretation, the definition of "hospital" set out in the Act includes any facility which provides acute, rehabilitative or chronic care. This definition covers those health care facilities known as "clinics". As a matter of both policy and legal interpretation, therefore, where a provincial plan pays the physician fee for a medically necessary service delivered at a clinic, it must also pay for the related hospital services provided or face deductions for user charges.
I recognize that this interpretation will necessitate some changes in provinces where clinics currently charge facility fees for medically necessary services. As I do not wish to cause undue hardship to those provinces, I will commence enforcement of this interpretation as of October 15, 1995. This will allow the provinces the time to put into place the necessary legislative or 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 accommodate the evolution of medical science and of health care delivery. This evolution must not lead, however, to a two-tier system of health care.
I indicated earlier in this letter that, while user charges for medically necessary services are my most immediate concern, I am also concerned about the more general issues raised by the proliferation of private clinics. In particular, I am concerned about their potential to restrict access by Canadian residents to medically necessary services by eroding our publicly funded system. These concerns were reflected in the policy statement which resulted from the Halifax meeting. Ministers of Health present, with the exception of the Alberta Minister, agreed to:
take whatever steps are required to regulate the development of private clinics in Canada, and to maintain a high quality, publicly funded medicare system.
Private clinics raise several concerns for the federal government, concerns which provinces share. These relate to:
weakened public support for the tax funded and publicly administered system;
the diminished ability of governments to control costs once they have shifted from the public to the private sector;
the possibility, supported by the experience of other jurisdictions, that private facilities will concentrate on easy procedures, leaving public facilities to handle more complicated, costly cases; and
the ability of private facilities to offer financial incentives to health care providers that could draw them away from the public system—resources may also be devoted to features which attract consumers, without in any way contributing to the quality of care.
The only way to deal effectively with these concerns is to regulate the operation of private clinics.
I now call on Ministers in provinces which have not already done so to introduce regulatory frameworks to govern the operation of private clinics. I would emphasize that, while my immediate concern is the elimination of user charges, it is equally important that these regulatory frameworks be put in place to ensure reasonable access to medically necessary services and to support the viability of the publicly funded and administered system in the future. I do not feel the implementation of such frameworks should be long delayed.
I welcome any questions you may have with respect to my position on private clinics and facility fees. My officials are willing to meet with yours at any time to discuss these matters. I believe that our officials need to focus their attention, in the coming weeks, on the broader concerns about private clinics referred to above.
As I mentioned at the beginning of this letter, divergent interpretations of the Canada Health Act apply to a number of other practices. It is always my preference that matters of interpretation of the Act be resolved by finding a Federal/Provincial/Territorial consensus consistent with its fundamental principles. I have therefore encouraged F/P/T consultations in all cases where there are disagreements. In situations such as out-of-province or out-of-country coverage, I remain committed to following through on these consultative processes as long as they continue to promise a satisfactory conclusion in a reasonable time.
In closing, I would like to quote Mr. Justice Emmett M. Hall. In 1980, he reminded us:
"we, as a society, are aware that the trauma of illness, the pain of surgery, the slow decline to death, are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability."
I trust that, mindful of these words, we will continue to work together to ensure the survival, and renewal, of what is perhaps our finest social project.
As the issues addressed in this letter are of great concern to Canadians, I intend to make this letter publicly available once all provincial Health Ministers have received it.
Yours sincerely, Diane Marleau Minister of Health
[Following is the text of the letter sent on August 8, 2018, to all provincial and territorial Ministers of Health by the federal Minister of Health, the Honourable Ginette Petitpas Taylor.]
Dear Minister,
It was a pleasure to see you recently at our Federal/Provincial/Territorial Health Ministers' Meeting in Winnipeg. As I have explained, when I was appointed as federal Health Minister, the Prime Minister tasked me with promoting and defending the Canada Health Act and quite specifically with eliminating patient charges for services that should be publicly insured. As you are aware, I have taken this responsibility seriously.
Following our conversations earlier this year, I was pleased to hear that all provinces and territories participated in officials' level discussions convened by Health Canada this Spring. We fine-tuned our approach based on the feedback provided in a series of multi- and bilateral meetings.
The purpose of this letter is to formally advise that I am proceeding with the three Canada Health Act initiatives I discussed with you. Taken together, the Diagnostic Services Policy, the Reimbursement Policy, and strengthened reporting, will provide me with tools to effectively administer the Act in the interest of all Canadians.
Diagnostic Services Policy
One of the overarching objectives of the Canada Health Act is to ensure that Canadians have access to medically necessary care based on their health needs and not their ability or willingness to pay. However, in many jurisdictions patients are charged for medically necessary diagnostic services provided at private clinics. Since the inception of the Canada Health Act, the federal position has always been that all medically necessary physician and hospital services – including diagnostic services – must be covered by provincial and territorial health insurance plans.
If an authorized provider has referred a patient for a medically necessary diagnostic test, the status of the procedure as a publicly insured service should not change simply because the service is delivered in a private clinic rather than in a hospital. I do not accept the premise that since some patients are willing to pay for expedited access to medically necessary services, they should be provided with a venue to do so. This practice results in patients jumping the queue twice – first, for the diagnostic service itself and then for any follow-up care that may be required. Simply put, this is not fair and goes against the fundamental principle of Canadian health care – that is, that access should be based on health need, not on the ability or willingness, to pay.
The Canada Health Act does not preclude the private delivery of insured services. Many insured health services are provided to Canadians in private clinics and are paid for by the provincial or territorial health insurance plan. As long as there are no patient charges, provinces and territories can provide insured services as they best see fit. However, my clarification of the status of medically necessary diagnostic services through this letter means, in effect, that any charges to patients for these services will be considered to be in contravention of the Canada Health Act.
I fully appreciate that it may take time in some jurisdictions to align provincial and territorial systems with the Diagnostic Services Policy. As I indicated in Winnipeg, the policy will not take effect until April 1, 2020 and reporting on any patient charges for diagnostic services will begin in December 2022 (for the fiscal year 2020-21). That would mean, in accordance with the Canada Health Act, that any Canada Health Transfer deductions would only be made in March 2023. If, in the interim, a jurisdiction has eliminated patient charges for diagnostic services, that jurisdiction would be eligible for reimbursement of deducted funds through the new Reimbursement Policy.
Reimbursement Policy
The Canada Health Act was enacted to eliminate the unfair practice of patient charges. The Act is clear – when a province allows patient charges, mandatory deductions to federal transfer payments must be made. During the first three years of the Canada Health Act, a provision in the Act allowed deductions to be refunded if the jurisdiction took the necessary steps to eliminate patient charges for services which should be publicly insured. This proved effective, and by 1987, patient charges were eliminated for most hospital and physician services across Canada. However, when this refund provision expired, the incentive structure under the Act went from a positive one, to a purely negative one. I believe this needs to change.
With the aim of emulating the success of the original refund provision, I am introducing a new Reimbursement Policy. Going forward, provinces and territories would be eligible to be reimbursed for deductions taken in respect of patient charges, should they demonstrate they have taken action to remove these barriers to access. The attached document provides details on the scope and application of the Policy. Any deductions made starting from March 2018 will be eligible for reimbursement under this Policy.
Strengthened Reporting
Finally, in order to ensure that I have the information needed to administer the Act in an even-handed manner and in order to report to Canadians on the state of their publicly funded health care insurance system, reporting from provinces and territories to Health Canada and from Health Canada to Canadians will be strengthened and standardized. Details, which were discussed with your officials this past Spring, will be communicated by my Deputy in the coming weeks. Again, respecting that a new approach cannot be instituted overnight, we will phase in the new reporting measures.
Canadians are rightfully proud of their health care system and have high expectations that their governments will work together to protect their access to it. I am confident these initiatives will help us meet that challenge and will safeguard our universal health care system for future generations.
I have appreciated our discussions to date and look forward to ongoing collaboration.
Yours sincerely, The Honourable Ginette Petitpas Taylor, P.C., M.P.
Reimbursement Policy for Provinces and Territories- Subject to Deductions under the Canada Health Act (the Reimbursement Policy)
Background
A fundamental premise of the Canadian health care system is that Canadians should have access to medically necessary physician and hospital services unimpeded by financial or other barriers. The Canada Health Act (CHA) was enacted in response to a growing concern that access to publicly insured health care services was increasingly undermined by point of service charges to patients.
The CHA established the conditions and criteria provinces must meet in order to qualify for their full cash contribution under the Canada Health Transfer (CHT). The Act also established discretionary and mandatory deductions for violations of the CHA principles and the extra-billing and user charges (EBUC) provisions of the Act, respectively. The Minister is required to make dollar-for-dollar deductions to a province's or territory's (PT's) CHT payments when EBUC are permitted. The intent of the CHA with respect to deductions is to encourage compliance with the Act and its objective of ensuring Canadians' access to health care services on uniform terms and conditions and without financial barriers.
At the time the CHA came into force, many jurisdictions had legal frameworks for public health insurance which either explicitly allowed EBUC to be levied on patients, or, by convention, had permitted such fees to become entrenched in their health care systems. In view of these factors, it was acknowledged that it would take time for PTs to align their systems with the values and requirements of the CHA. The Act, therefore, included a provision for the first three years (1984-1987) which, in effect, provided refunds of amounts deducted from federal transfers for EBUC violations once the PT succeeded in eliminating EBUC.
PTs adopted legislation governing their public health insurance systems which mirrored, and in most cases went well beyond, the requirements of the CHA. As a result, over $244 million was refunded to seven PTs in respect of patient charges levied in the 1984-1987 period. The advent of the CHA, including the refund provision, helped eliminate EBUC for a considerable period of time in most parts of the country and in most care settings.
Time for a New Reimbursement Policy
Despite provisions discouraging or prohibiting EBUC in both federal and PT legislation, there are still instances of patients paying for access to insured health care services in some jurisdictions. As was the case in 1984, these charges put at risk the fundamental value of universal access to health care.
Some jurisdictions have been active in investigating allegations of patient charges, adopting legislative and regulatory measures to deter EBUC, ensuring that patients are reimbursed and that providers or institutions who contravene PT law (and the CHA) are disciplined. These governments are to be commended for their vigilance on behalf of patients.
Given the success of the original refund provision of the CHA in eliminating EBUC, the federal government is implementing a new Reimbursement Policy for Provinces and Territories Subject to Deductions under the Canada Health Act (the Reimbursement Policy). Under this new policy, if a province or territory is subject to a deduction, the federal Minister of Health has the discretion to provide a reimbursement if the PT comes into compliance with the Act by the end of the calendar year.
Current Process
Under the CHA's Extra-billing and User Charges Information Regulations (the Regulations), PTs are obligated to report to Health Canada on EBUC occurring within their jurisdiction. This takes the form of a financial statement submitted each year, by December 16, which describes any EBUC activity occurring in the fiscal year two years previous. If the Minister does not receive a statement, or believes the information was not provided in accordance with the Regulations, the Act obligates the Minister to estimate an amount after consultation with the PT. The CHT payments to the jurisdiction are then reduced by a corresponding amount in March of the following year.
Working Together to Eliminate Patient Charges
The objective of the Reimbursement Policy is to work collaboratively with PTs subject to a CHT deduction to ultimately eliminate these patient charges. When a PT is informed it will be subject to a CHT deduction for EBUC (typically in January/February), the conditions for reimbursement will also be outlined. In instances where the PT has already eliminated patient charges and a sufficient period of time has elapsed to assure Health Canada that the circumstances that led to these charges have been addressed, reimbursement may be made immediately. Where such charges are ongoing, Health Canada will work with PT officials on the elements of an action plan to meet the conditions for reimbursement. Action plans, and PT progress on meeting them, will be published in the Canada Health Act Annual Report.
To be considered for reimbursement, the jurisdiction would need to demonstrate it has followed through on the agreed upon action plan within the specified time period – typically 12 months but no more than two years following the initial deduction. Because the circumstances leading to deductions will vary from province to province, so will the action plans. Nonetheless, it is expected that all action plans will require the PT to submit the following documents to Health Canada in the January following the deduction:
A financial statement of any EBUC levied in the jurisdiction since the deduction
A report on the steps the jurisdiction has taken to eliminate EBUC, and how these charges have been addressed
An attestation as to the completeness and accuracy of the information submitted
Upon review of the jurisdiction's report, if the Minister is satisfied that the elements of the action plan have been fulfilled, the PT would receive a reimbursement. However, if the Minister is not satisfied that the conditions were fulfilled, no reimbursement would occur and the deduction amount would be forfeited. Following an initial deduction and reimbursement cycle, if the Minister remains satisfied that appropriate action has been taken, the Reimbursement Policy would allow for the immediate reimbursement of subsequent CHT deductions.
In order to qualify for continued consideration under the Reimbursement Policy, a PT must also comply with the regular reporting requirements set out in the Regulations and submit an accurate EBUC financial statement to Health Canada in the December following the CHT deduction and commit to doing so on an annual basis going forward.
Although not an interpretation letter, the Dispute Avoidance and Resolution (DAR) process is a part of the history of federal-provincial-territorial collaboration and the Canada Health Act. In April 2002 the federal Minister of Health, the Honourable A. Anne McLellan, wrote to the Alberta Minister of Health, the Honourable Gary Mar, outlining the DAR agreement. A copy of the letter was sent to all other provincial and territorial Ministers of Health. The DAR was formally agreed to by all governments, except Quebec via the 2004 First Ministers’ Meeting Communique entitled "A 10-year Plan to Strengthen Health Care". The DAR process was meant to meet federal and provincial/territorial interests of avoiding disputes related to the interpretation of the criteria of the Canada Health Act, and when this was not possible, resolving disputes in a fair, transparent and timely manner.
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.
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.
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.
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. 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.
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
The provisions described apply to the interpretation of the principles of the Canada Health Act.
To avoid and prevent disputes, governments will continue to:
Health Canada commits to provide advance assessments to any province or territory upon request.
Where the dispute avoidance activities between the federal government and a provincial or territorial government prove unsuccessful, either Minister of Health involved may initiate dispute resolution by writing to his or her counterpart. Such a letter would describe the issue in dispute. If initiated, dispute resolution will precede any action taken under the non-compliance provisions of the Act.
As a first step, governments involved in the dispute will, within 60 days of the date of the letter initiating the process, jointly:
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.
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.
Governments will report publicly on Canada Health Act dispute avoidance and resolution activities, including any panel report.
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.
Under the Reimbursement Policy, provinces and territories (PT) subject to a Canada Health Transfer (CHT) deduction as a result of patient charges are eligible for reimbursement should they demonstrate action has been taken to come into compliance with the Canada Health Act and the patient charges have been eliminated.
Following a CHT deduction as a result of patient charges, Health Canada officials work collaboratively with PT officials to reach a mutually agreed upon Action Plan. Given the circumstances leading to deductions will vary by jurisdiction, so too will the conditions for reimbursement, and the resulting Action Plans. However, the overarching objective of the Reimbursement Policy is the effective elimination of patient charges.
In addition to the Reimbursement Action Plan, PTs must submit annual progress reports to Health Canada that outline the degree to which the plan has been implemented. Upon review of the jurisdiction's report, if Health Canada is satisfied that key elements of the Action Plan have been fulfilled, the PT could receive a partial or full reimbursement. Following an initial deduction and reimbursement cycle, if Health Canada remains satisfied that patient charges have been eliminated, the Reimbursement Policy allows for the immediate reimbursement of subsequent CHT deductions.
Action plans, and PT progress reports on meeting their plans, are published on the following pages.
For further details on the Reimbursement Policy please refer to Annex C which includes the full text.
[Following is the text of the Newfoundland and Labrador Reimbursement Action Plan and January 2023 Status Update]
In the winter of 2017-2018, the Department of Health and Community Services (HCS) received phone calls from Medical Care Plan (MCP) beneficiaries complaining that they had paid out of pocket for cataract surgery.
In February 2018, HCS issued a Public Service Announcement (PSA) in an effort to identify beneficiaries in the province who felt that they had been billed inappropriately for insured cataract surgery and created a hotline for reporting of such instances.
HCS plans to reimburse patients for the excision of the cataract and intraocular lens replacement at a rate of $574.47 per eye when patients can produce documents verifying that they have paid for cataract surgery in a private clinic until June 15, 2018. The amount of $574.47 represents the professional fees billable for the excision of the cataract ($473.09) and insertion of the intraocular lens ($101.38). HCS is not reimbursing the costs of non-insured services associated with providing cataract surgery in a private clinic.
On March 28, 2018, in Jackman v. Newfoundland and Labrador, the Applicants filed an application for declaratory relief with the Supreme Court of Newfoundland and Labrador, General Division, on three matters:
On March 6, 2019, Justice Goodridge declared that:
This action plan was created as part of the Reimbursement Policy under the Canada Health Act and with the intention of eliminating patient charges for medically necessary cataract surgery. These efforts have been made in hopes of obtaining a reimbursement for Canada Health Transfer deductions in the amount of $1,349 taken in March 2019 for fiscal year 2016-2017, and in hopes of obtaining an immediate reimbursement for deductions resulting from the remaining patient charges that occurred in subsequent fiscal years.
Starting in late 2017, the Department of Health and Community Services (HCS) began receiving phone calls from Medical Care Plan (MCP) beneficiaries complaining about out-of-pocket charges being levied for cataract surgery. In February 2018, HCS issued a Public Service Announcement (PSA) and created a Cataract Surgery Information Line in an effort to identify beneficiaries who may have been billed inappropriately for insured cataract surgery.
On June 15, 2018, amendments to the Medical Care Insurance Insured Services Regulations were introduced to clarify that "the medically necessary removal and replacement of a cataractous lens by any procedure is an insured service and shall be performed in a hospital or a facility designated by the Lieutenant-Governor in Council".
As of January 1, 2019, HCS adopted the aspheric lens as the new standard for cataract surgery, ensuring that patients would no longer be billed for this lens when inserted during insured cataract procedures.
In January 2019, HCS announced that cataract surgery would be available in private offices throughout the province in the near future. In April 2019, an Amending Agreement to add Schedule "O" to the 2013-2017 Memorandum of Agreement was signed by HCS and the Newfoundland and Labrador Medical Association (NLMA). Schedule "O" outlines an agreement between HCS and the NLMA with respect to service fees for cataract surgeries performed in designated facilities. In January 2021, the Lieutenant-Governor in Council designated two non-hospital facilities to provide insured cataract surgery. A third facility was designated in April 2022.
In February of 2020, a PSA was issued to outline a Reimbursement Process for Cataract Surgeries.
This year, the Department of Health and Community Services conducted a review of the provincial allocation of out-of-hospital cataract surgery and the Policy for the Provision of Cataract Surgery in Non-Hospital Designated Facilities. This review included a calculation of Total Predicted Regional Demand (TPRD) for cataract surgery in each region of the province, as well as evaluating wait lists, national benchmarks for wait times, and adherence to the policy by designated facilities. As a result of this evaluation, the Department approved a one-time increase of 3,300 procedures to the regional caps on cataract surgery in designated facilities. This increase will be in place from October 1, 2022 until March 31, 2024 (18 months total) and is in addition to the baseline number of procedures (3,500) provided each year to designated facilities across the province.
Following the 2018 PSA, HCS issued another PSA on the Reimbursement Process for Cataract Surgeries on February 20, 2020. As part of this process, HCS established a dedicated phone line (1-844-957-1401) and email address ([email protected]) for patients. HCS also directly contacted individuals who had previously reached out to HCS via the Cataract Surgery Information Line of 2018. As part of the Reimbursement Process, HCS reviewed information provided from new patients that had not previously contacted HCS until the 2020 PSA was released. Last year, HCS reported a total of $126,957.87 in user charges identified and paid to 129 individuals for procedures performed on 221 eyes prior to the legislative amendments introduced on June 15, 2018. This total of $126,957.87 represents the professional fees for cataract surgery for 129 patients. There has been one additional instance of a user charge identified for payment for a procedure provided to a patient on one eye in 2017, making the total user charges identified $127,532.34 for 130 individuals for 222 eyes.
Not all patients who contacted HCS have been eligible for reimbursement. There were several reasons patients did not meet the eligibility criteria for reimbursement. For example, under the Reimbursement Process, June 15, 2018 was established as the cut-off date for reimbursement. This date coincided with the coming into force of the legislative amendments. As such, patients whose procedures were performed after June 15, 2018, were not eligible for reimbursement, and therefore have not been reimbursed. In other instances where a claim was denied, the documentation submitted by the patient may not have provided sufficient evidence that the service provided was an insured cataract procedure.
While the reimbursement cut-off date has passed, the review process remains open. HCS continues to review documents submitted by patients and report any instances of patient user charges. There were no such instances of user charges reported for 2020-21. However, from May to November 2022, HCS received documents from four people for analysis for user charges associated with relevant procedures occurring in the spring to fall of 2022:
In 2020, HCS developed the Policy for the Provision of Cataract Surgery in Non-Hospital Designated Facilities, which outlines the requirements and expectations for these facilities. Section 14.1 of the policy specifically deals with expectations regarding extra-billing and user charges, which are prohibited. The ophthalmologist has a duty to make sure that the patient understands that all insured services are available without any charge (to the patient). Non-hospital designated facilities must provide an itemized list of services billed to ensure clarity between insured and billable non-insured services. Non-hospital designated facilities must also post a Patient Information Sheet in visible areas for public viewing in their offices and patients receiving cataract surgery must also receive and sign a copy to indicate their understanding. HCS will investigate any patient complaints of suspected extra-billing or user charges. The Lieutenant-Governor in Council has the authority to suspend or cancel a non-hospital facility's designation status if the non-hospital designated facility has failed to comply with the policy.
[Following is the text of the Ontario's Reimbursement Action Plan and February 2023 Status Update]
Ontario's Extra-Billing and User Charges (EBUC) Legislative Framework
Ontario recognizes that medicare is a fundamental Canadian value and its preservation is essential for the health of Ontarians, now and in the future. Ontario continues to support the prohibition of two-tier medicine, extra-billing and user fees in accordance with the Canada Health Act (CHA) and is committed to ensuring that accessibility is a central principle of medicare in Ontario.
The Health Insurance Act (HIA), the Independent Health Facilities Act (IHFA) and the Commitment to the Future of Medicare Act (CFMA) comprise the legislative framework through which Ontario actively protects insured persons from extra-billing and user charges (EBUC).
The Ontario Health Insurance Plan (OHIP) and all insured services are set out under the HIA and its regulations.
Commitment to the Future of Medicare Act (CFMA):
The CFMA prohibits any person or entity from charging unauthorized payments for all or part of an OHIP-insured service rendered to an insured person. Such charges include extra-billing (i.e. charges to insured persons for insured physician and dental-surgical services) and user charges (i.e. charges to insured persons for non-physician/dental surgical services provided in conjunction with insured services at a hospital).
The CFMA also prohibits providers and other entities from providing preferred access to an insured service conditional on the payment of a fee, which is called queue-jumping, and from making the provision of an insured service conditional on paying a block fee for uninsured services.
The CFMA applies regardless of the type of facility or setting in which a service is rendered.
Independent Health Facilities Act (IHFA):
The IHFA prohibits any person from charging facility fees except in accordance with the Act. A facility fee is a charge, fee or payment in respect of a service or operating cost that supports, assists and/or is a necessary adjunct to an OHIP-insured service and is not part of the insured service.
Regardless of whether an insured service is provided in a licensed IHF or any other community setting, a charge or payment in respect of a service or operating cost that supports, assists and/or is a necessary adjunct to an insured service, but is not part of the insured service, that is not in compliance with the IHFA is an illegal facility fee.
CFMA Program
Through a dedicated program (CFMA Program), the Ontario Ministry of Health (the ministry) reviews all possible cases of EBUC brought to its attention. Charging facility fees contrary to the IHFA may also have implications under the CFMA, and therefore, the ministry's CFMA Program also reviews allegations of illegal facility fees under the IHFA in conjunction with the ministry's IHF program. If, as a result of a review, it is determined that a patient has paid an unauthorized payment (i.e. extra-billing) and/or user charge, the ministry ensures that the full amount is reimbursed to the patient.
As noted above, the current Ontario legislative framework (HIA, CFMA, and IHFA) protects insured persons from being charged for OHIP-insured services and for the associated overhead/facility fee costs of providing such services.
In Ontario, physician services associated with both surgical and medical abortions are insured under OHIP regardless of the setting where the services are provided. The "overhead" or "facility" costs associated with medical abortions are included in the fee paid by OHIP for the insured physician service, and Mifegymiso, the drug used in the performance of medical abortions, is also publicly funded. The overhead/facility costs associated with performing surgical abortions in hospitals are insured hospital services funded through a hospital's global budget.
The ministry also licenses and funds four non-hospital clinics for the overhead/facility costs associated with surgical abortion services under the IHFA. There are other non-hospital surgical abortion clinics operating in Ontario that are not licensed and funded for overhead/facility costs under the IHFA. These clinics do not receive any funding from the ministry for the facility fee (overhead) component of the service.
Under provincial legislation, patients cannot be charged for insured physician services or insured hospital services (CFMA) or for the cost of premises, equipment, supplies or personnel used to perform insured services (IHFA), regardless of the setting in which the services are received (e.g., non-hospital clinic licensed under the IHFA, nonhospital/non-IHFA-licensed clinic).
Additionally, the ministry promptly reviews all potential contraventions of the HIA, CFMA and IHFA that come to its attention. This is important to ensure that all patients are not charged for insured health care services.
Health Canada has expressed concerns that some non-hospital surgical abortion clinics in Ontario may be charging patients mandatory fees ("clinic" or "block" fees) in order to access insured surgical abortion services contrary to the CHA.
Health Canada's specific concerns are based, in part, on inquiries conducted by Health Canada staff members posing as patients who were told by clinic staff that they would be required to pay a mandatory fee ("clinic" or "block" fee) in order to access insured surgical abortion services or where clinic websites were not clear with respect to fees.
Additionally, Health Canada made a deduction to Ontario's March 2021 Canada Health Transfer (CHT) in the amount of $13,905.00 to reflect user charges found at one nonhospital surgical abortion clinic, as reported on Ontario's FY 2018-19 EBUC report.
To address the concerns raised by Health Canada with respect to abortion services dating back several years, Ontario has conducted CFMA reviews into several private abortion clinics to ensure that their fee policies are in compliance with Ontario legislation.
Ontario has taken extensive efforts to address Health Canada's concerns with respect to insured abortion services in Ontario.
Since 2017, the ministry has undertaken 9 proactive reviews of five private surgical abortion clinics in Ontario, four of which were initiated in response to concerns raised by Health Canada.
Based on the reviews undertaken, with the exception of one clinic, the ministry identified no instances of EBUC.
Additionally, the ministry has received very few complaints directly from patients who have been charged in association with insured surgical abortion services in Ontario. In addition to the proactive investigations noted above, since 2003, the ministry has undertaken only five other investigations associated with specific patient complaints related to charges by community-based abortion clinics. In all cases, no cases of EBUC were identified. As a result of Health Canada's concerns, the ministry promptly opened new reviews under the CFMA into two of the three clinics in question. The ministry had already recently concluded a review of the third clinic.
The table below summarizes the investigations as requested by Health Canada:
Ontario is committed to revisiting the current framework for the funding of insured surgical abortion services in Ontario. The changing landscape and complexity of the current funding model for abortion services in Ontario provides an opportunity to consider options to enhance provision of care across different health service delivery settings for abortion services beyond those currently funded by the ministry.
An appropriate assessment of service delivery options, with an eye to funding all surgical abortion service providers/facilities, would need to be taken with consideration of the potential impact to patients, currently funded service providers, as well as the special nature of abortion services.
Ontario has specific legislation to ensure safe access to abortion care, the Safe Access to Abortion Services Act, 2017. This legislation protects the safety, security, health and privacy of patients and abortion service providers in their health service delivery settings and homes.
Any updates to the funding of abortion services in Ontario would need to carefully consider the safe access zones and the unique nature of abortion services.
Ontario trusts that Health Canada will accept the significant efforts being made by Ontario to ensure that the abortion landscape in Ontario protects patients from facing barriers in accessing insured abortion services and that these efforts will be recognized by Health Canada by way of a reimbursement of the March 2021 CHT deduction.
Ontario remains committed to revisiting the current framework for the funding of insured surgical abortion services in Ontario.
This is complex work given the rapidly evolving changing landscape, the challenges of funding models and the special nature of the service itself, within the context of a continuing pandemic.
An appropriate assessment of service delivery options needs to consider the potential impact to patients, to currently funded service providers, as well as the special nature of abortion services. Abortion services in Ontario are currently funded through physician's service agreements, facility fee licenses and hospital global budgets.
Ontario is currently focusing its efforts on improving the legislative and funding framework for Independent Health Facilities as a necessary first step before returning to an examination of the structural funding model of abortion clinics specifically.
Due to this necessary foundational work, Ontario requests another year to complete the review of the framework for funding insured surgical abortion services in Ontario.
Ontario understands that this refocus means that Ontario will forfeit reimbursement of its March 2021 CHT deduction in the amount of $13,905 as required by Health Canada.
[Following is the text of the British Columbia Extra-Billing Elimination Action Plan and December 2022 Status Update]
This report outlines British Columbia's (BC) Action Plan to address extra-billing. Central to the plan is the implementation of Bill 92, the amendment to the BC Medicare Protection Act (Appendix A), which strengthens the province's legislative provisions against extra billing.
The Canada Health Act requires the Federal Government to impose financial penalties on provinces where extra billing has occurred. As a result, BC has been subject to reductions in the amount it receives under the Canada Health Transfer. Previous federal deductions reported by BC to Health Canada have been approximately $200,000 per year. In 2017-2018, the Ministry of Health (MoH) audited three private clinics. Based on the audits, Health Canada estimated that extra billing in BC for the 2015-2016 fiscal year was $15.9 million and as a result, BC's federal health funding was reduced by that amount.
In the spring of 2018, BC's Minister of Health announced, in part to bring BC in compliance with the Canada Health Act, that the Government would bring into force the remaining provisions of the 2003 Bill 92 to address the province's ability to respond to and address extra billing. Most of these provisions came into force on October 1, 2018. The key changes include:
In addition to the above changes, Bill 92 includes a prohibition for charging in relation to diagnostic services (s. 18.1). This provision is scheduled to take effect on April 1, 2019. Bringing into force these provisions serves to strengthen enforcement against extra billing and reinforces the province's commitment to universal public health care.
The enforceability of the Bill 92 provisions has been challenged in Court in Cambie Surgeries Corporate v. British Columbia (Attorney General). On November 23, 2018, the BC Supreme Court issued an injunction enjoining the enforcement of the extra billing provisions in the Act until June 1, 2019 or further order of the Court (the Court Order). BC is appealing this decision.
Since BC's announcement to bring into force Bill 92, a number of steps have been taken. The following provides a summary of the province's approach to implementation.
A letter serving notice of the changes was issued to all registered medical practitioners, accredited diagnostic facilities and private surgical clinics on September 10, 2018 (Appendix B). These letters were sent via registered mail to ensure there is a record of them being delivered.
Sections of the BC government website aimed at medical practitioners – Practitioner-Specific Information – have been updated to articulate the changes that have been made. This includes an FAQ document for practitioners, as well as contact information for further questions (Appendix C).
Briefings were conducted prior to October 1, 2018, with various associations including: Doctors of BC, the BC College of Physicians and Surgeons, the Canadian Medical Protective Association and the Vice Presidents of Medicine for the Health Authorities, to ensure awareness around the legislative changes and new expectations.
On April 4, 2018, the MoH issued a press release announcing the province would be bringing into force the remaining provisions of Bill 92, effective October 1, 2018. An additional press release was issued on September 7, 2018, providing an overall update on Bill 92 and reporting a six-month extension to April 1, 2019 of the Medicare Protection Act measures applicable to diagnostic services.
A number of relevant sections of the BC government website aimed at the public have been updated to prominently feature alerts that will link patients directly, through multiple paths, to information concerning extra billing. These include:
Applicable patient information on the changes to the Medicare Protection Act and the ability to seek reimbursement from the Medical Services Commission is profiled at Additional Fees and Charges. Updates also include an FAQ document for patients, as well as contact information for further questions (Appendix D).
The MoH will monitor ongoing patient inquiries and consider additional formats to make information available to the public, as required.
Currently, there are ten contracts between Health Authorities and private clinics for surgical services. The MoH issued a letter on September 13, 2018 notifying all Health Authorities of expectations about contracting between Health Authorities and private clinics for the provision of medical services (Appendix E). This included a requirement for all Health Authorities to amend their current surgical services contracts with private clinics to include termination provisions in the event of extra billing. As a requirement of the amended contracts, medical practitioners and clinics have been required to sign compliance statements (Appendix F). This letter of expectations was revised following the Court Order (Appendix G), as was the compliance statement – which is now referred to as a "notice to physician" (Appendix H).
The MoH has developed a series of operational processes to protect patients from extra billing. However, due to the recent Court Order, the Ministry is not able to implement these processes at this time. These processes include: processing complaints, investigating allegations and making a determination as to whether extra billing has taken place. Once the Ministry is able to move forward, these processes will enable the Medical Services Commission to reimburse beneficiaries directly, assume debt on behalf of a beneficiary and recover the charge from the practitioner and/or clinic. In addition, once enforcement is not prohibited by the Court Order, extra billing offences may be referred to the MoH's Audit and Investigations Branch and the Special Investigations Unit for the purpose of recommending charges and penalties, where appropriate. As noted above, the Ministry is appealing the recent Court Order and will be seeking for the injunction to be overturned.
On August 8, 2018, the Honourable Ginette Petitpas Taylor, Minister of Health Canada, wrote to BC Minister of Health, Adrian Dix, regarding the Federal Government's Diagnostic Services Policy. In the letter, Minister Petitpas Taylor stated:
"I fully appreciate that it may take time in some jurisdictions to align provincial and territorial systems with the Diagnostic Services Policy. As I indicated in Winnipeg, the policy will not take effect until April 1, 2020, and reporting on any patient charges for diagnostic services will begin in December 2022 (for the fiscal year 2020-2021.) That would mean, in accordance with the Canada Health Act, that any Canada Health transfer deductions would only be made in March 2023. If in the interim, a jurisdiction has eliminated patient charges for diagnostic services, that jurisdiction would be eligible for reimbursement of deducted funds through the new Reimbursement Policy."
Further, on September 20, 2018, Deputy Minister of Health Canada, Simon Kennedy emailed all of the provinces and territories on the issue of the diagnostic services. In his email, it stated:
"You will note the Minister has indicated that the Diagnostic Services Policy will take full effect from April 1, 2020. This policy is a clarification of the application of the CHA to diagnostic services. It confirms the federal position that medically necessary diagnostic services are insured services, regardless of the venue where the services are delivered. This means that provinces and territories not currently reporting to Health Canada on patient charges in respect of medically necessary diagnostic services will be required to do so as of December 2022 (for the fiscal year 2020-2021). This extended phase-in period is to allow any jurisdiction where patient charges for diagnostic services are permitted to make the changes necessary to align with the Policy. Naturally, moving earlier than 2020-2021 to eliminate such charges is strongly encouraged."
BC is committed to addressing patient charges for diagnostic services. To that end, in March 2018, the BC Surgical and Diagnostic Imaging Strategy was announced which seeks to provide faster access and to reduce wait times for all medical imaging modalities within the province. The priority focus for 2018-2019 was providing faster access to magnetic resonance imaging (MRI), which included by performing 37,000 more MRI exams by the end of March 2019, establishing a centralized intake and pooled referrals approach (where appropriate) and to reduce wait times for high priority patients. To support these initiatives, $11 million in additional funding was made available to the Health Authorities.
BC believes the above steps will address the demand for medically necessary MRIs in the province. In addition, as of April 1, 2019, BC will bring into effect Section 18.1 of the Medicare Protection Act, which will make it illegal for a medical practitioner to charge for diagnostic imaging. This will deter the private delivery of the service and provide greater protection to patients being charged for medically necessary diagnostic services.
With regard to the Laboratory Services Act, the Ministry plans to bring forward in the fall/winter of 2019-2020 a proposed series of consequential amendments for Cabinet to consider. These changes are not anticipated to be material in nature; rather, they are to ensure elements in the Laboratory Services Act are consistent with the updated Medicare Protection Act.
The MoH has completed three audits of private clinics – False Creek Healthcare Centre, Seafield Surgical Centre, and Okanagan Health Surgical Centre. The results of these audits were shared with Health Canada in accordance with the agreement signed by our respective ministers in 2017.
The MoH has established an audit unit that is responsible for the ongoing audit of existing private surgical centers, and in the 2018-2019 fiscal year is aiming to complete a further three audits, subject to impediments due to the Court Order, bringing the total completed and underway to ten, including Cambie. The clinics are selected on a risk-based approach, taking into account factors such as complaints made by patients, types of services offered, number of physicians providing services and evidence from clinics’ websites that they extra bill.
The purpose of the audits is two-fold:
Subject to clarification from the Court, the MoH is committed to full transparency and will continue to work with Health Canada in reviewing audit findings as the work is completed. Going forward, it is suggested that the monthly conference calls to discuss audit findings are re-established.
BC commits to submitting a complete and accurate 2016-2017 extra billing and user charges financial statement to Health Canada in December 2018, per the reporting requirements set out in the Canada Health Act and Regulations.
As per the Reimbursement Policy, BC also commits to submitting a January 2019 report to Health Canada, assessing the degree to which the elements of the Action Plan have been completed. This report will include:
In summary, BC's MoH is appealing the Court Order to be able to use the Bill 92 provisions, and, if successful, will monitor and assess the impact of the implementation of Bill 92. BC's MoH will also determine whether further changes to policy and/or legislation are warranted to address extra billing. By moving forward with the above noted actions, BC believes it has taken the necessary steps to address extra billing within the province and is seeking reimbursement from Health Canada for the 2018-2019 $15.9 million penalty.
Pursuant to sections 18 and 19 of the Canada Health Act (CHA), we submit the December 2022 status update to British Columbia's (BC) Extra-billing Elimination Action Plan.
The status update below demonstrates BC's ongoing commitment to upholding the principles of the CHA under challenging circumstances, and we reiterate the expectation that steps are taken under the Federal reimbursement policy to reimburse BC for all extra-billing penalties levied to date, including any penalty that may arise from the filing related to practices in effect in 2020-2021.
In September 2020, the Province saw a successful outcome in the landmark Cambie Surgeries Corporation litigation. The appeal was heard in June 2021, and a decision was rendered by the BC Court of Appeal on July 15, 2022. The decision upheld the BC Supreme Court decision in the Province's favour. Cambie has applied for leave to appeal to the Supreme Court of Canada.
On December 8, 2020, a judge of the Court of Appeal issued a limited form of injunction which prohibited the Medical Services Commission (MSC) from exercising its powers of enforcement under sections 21(2) and (3), 45.1 and 46(5.1) and (5.2) of the Medicare Protection Act (MPA) in respect of any private surgeries where a patient has been scheduled for a date beyond Ministry of Health (the Ministry) wait time benchmarks or where a surgery has not taken place by the date set according to such wait time benchmarks. This injunction was in effect until September 30, 2021.
The successful outcome through two levels of provincial court highlights the significant effort and resources that BC has put forward to uphold our publicly funded healthcare system. It is important to highlight that during the 2020-2021 reporting year, the Province took all actions reasonably within its power to enforce the provisions of the MPA and uphold the principles of the CHA within the bounds of the injunction that was in place as described above.
A history of BC's efforts to enhance extra-billing enforcement and the lengthy impact of the Cambie litigation follows.
In October 2018, BC brought the remaining provisions of the Medicare Protection Amendment Act Bill 92 (2003) into force to address the province's ability to respond to extra-billing and to bring BC into compliance with the CHA.
The key changes to the MPA resulting from Bill 92 include:
*To date, the powers to lay fines and reimburse beneficiaries have not been exercised, due to various injunctions that have been in place. However, given the successful outcome at the BC Court of Appeal the Province is currently working to operationalize these powers.
The following timeline covers the cumulative impact of Cambie Surgeries Corporation vs. British Columbia (Attorney General) on the implementation of Bill 92.
BC has committed significant resources and incurred significant expense to ensure the successful conclusion of this trial and throughout the appeal hearing. With the successful outcome at the BC Court of Appeal the Ministry is focusing on ongoing enforcement and operationalizing provisions of Bill 92 relating to fines and reimbursements.
As a term of the December 2020 injunction, private clinics who provided surgeries pursuant to the injunction were required to maintain adequate records to permit the MSC to determine that those surgeries are in accordance with the court order and make those records available to the MSC on demand.
In accordance with this term of the injunction, on February 5, 2021, the MSC issued letters to 50 Non-Hospital Medical Surgical Facilities requesting monthly reporting of data, for the term of the interim order, to ensure compliance with the interim order. On June 3, 2021, a second round of letters was sent to 13 clinics who failed to respond to the first letter.
102 cases (surgeries) were determined to be non-compliant with the injunction. The cases, up to March 31, 2021 (69 cases), are reported in this year's extra-billing and user charges report for 2020-2021 The remaining cases, where service was provided between April 1, 2021 and September 30, 2021, will be reported on next years extra-billing and user charges report for 2021-2022.
On August 16 to 18, 2021, the Billing Integrity Program (BIP) conducted an on-site audit of the Cambie Surgery Centre's compliance with the December 8, 2020, British Columbia (BC) Court of Appeal1 Interim Order. In total BIP reviewed 23 surgeries that occurred under the Interim Order between December 8, 2020 and August 16, 2021.
Overall, BIP found two surgeries that were conducted prior to the wait time benchmark being reached. BIP also found an additional eight surgeries where, although completed after the wait time benchmark, the medical inspector expressed concerns over the diagnostic and/or priority codes used to set the benchmark times.
Sections of the BC government website aimed at medical practitioners have been updated and placed on the main landing page to raise awareness amongst physician about what is being communicated to patients regarding appropriate and inappropriate billing so that they may better understand patient expectations for appropriate billing.
New information was published by the Medical Services Commission in October 2022 regarding physician enrolment status: https://www2.gov.bc.ca/gov/content/health/practitioner- professional-resources/msp/physicians/physician-enrollment-status. This information clarifies, for physicians and their patients, the implications of de-enrolling from MSP.
The Ministry has provided patients with a description of benefits and a link to the description of extra-billing at the following webpage: https://www2.gov.bc.ca/gov/content/health/health-drug- coverage/msp/bc-residents/benefits .
The Ministry also has a description of extra-billing along with the form for submitting a request for investigation for patients who believe themselves to have been extra billed: https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/msp/bc- residents/benefits/additional-fees-and-charges
Links to the description of extra-billing and the form are also available with the description of Services Covered by the Medical Services Plan (MSP): https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/msp/bc- residents/benefits/services-covered-by-msp, and Services Not Covered by MSP: https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/msp/bc- residents/benefits/services-not-covered-by-msp .
British Columbians have the right to expect that they will not be asked by physicians to pay out of pocket for insured services. The Ministry believes that its communication strategy has been effective at reducing those situations and remains committed to working towards their elimination. The Ministry will monitor ongoing patient inquiries and consider additional formats to make information available to the public, as required.
On April 1, 2020, the federal Diagnostic Services Policy (DSP) came into effect, clarifying the federal government's position that medically necessary diagnostic services, regardless of the venue in which they are delivered, are considered insured services under the Canada Health Act, and must be covered by provincial and territorial health insurance plans. Medical necessity for diagnostic imaging is determined when a patient receives a referral or requisition from a medical practitioner for the test or procedure. Medically necessary diagnostic services encompass a range of scanning modalities, including MRI, CT, ultrasounds, and echocardiograms. Accordingly, any patient charges levied for these services must be included in the annual extra-billing and user charges reporting to Health Canada.
As mentioned previously in the Action Plan, BC is currently awaiting a decision on bringing section 18.1 of the MPA into force. Section 18.1, once in force, will expand the current prohibition against approved diagnostic facilities charging for medically necessary diagnostic services that are benefits under the MPA or the Hospital Insurance Act to include those without MPA approval.
Charges to a beneficiary in relation to medically necessary diagnostic services provided at any diagnostic facility in BC would be prohibited in almost all cases.
The Ministry works closely with the MSC to ensure that operational processes are designed to protect patients from extra-billing. The Ministry processes patient complaints and investigates allegations of extra-billing to determine whether extra-billing has taken place. Where possible, throughout the investigation, the Ministry seeks to resolve the complaint by communication and education with the physician.
Throughout 2020-2021 the Ministry was subject to various court orders and injunctions related to enforcement of extra-billing which sometimes deterred the ability to investigate complaints.
In 2020-2021 there were a total of five patient complaints where extra-billing was determined to have likely occurred. In four of the five cases, the Ministry was successful in getting the physician to reimbursement the patient, leaving one unresolved complaint where no reimbursement was provided.
The Ministry worked closely with the MSC and supporting medical and legal experts, to investigate these complaints in a timely fashion and ensure that both patients and practitioners receive clear expectations for appropriate action.
BC has seen success in curbing extra-billing through government contracts with private clinics. BC is committed to curbing extra-billing and user charges in the province to enhance publicly funded health care.
In 2020-2021, there were 8 facilities which the HAs contracted with, in compliance with the CHA, to perform surgeries. The Ministry issued a letter on September 13, 2018, notifying all HAs of expectations ("letter of expectation") about contracting between HAs and private clinics for the provision of medical services. This included a requirement for all HAs to amend their current surgical services contracts with private clinics to include termination provisions in the event of extra-billing. As a requirement of the amended contracts, medical practitioners and clinics have been required to sign compliance statements. Physicians can only provide contracted surgical services once the compliance statement is signed. The letter of expectation and compliance statements were revised following the November 23, 2018, BC Supreme Court injunction prohibiting the enforcement of the extra-billing provisions (s. 17, 18, and 45 of the MPA).
The compliance statement to physicians requires acknowledgement by physicians of the termination provisions in the contract between the HA and their clinic pertaining to extra-billing. These provisions apply to the physician's service under contract (insured services) as well as services undertaken by the physician in clinics outside of the contract (the latter would be insured services provided at the clinic).
Currently, the regional HAs monitor the surgical contracts for compliance with all provisions. Since implementation in September 2018, the HAs have not terminated any contracts with private surgical clinics over performance or compliance issues. The Ministry is confident that the agreements are being followed by the physicians and HAs. Overall, the Ministry views this current productive dynamic between HAs and clinics (formerly providing private services) as demonstrative of the value of contractual arrangement to bring private surgical services back into the public system. This approach simultaneously eliminates extra-billing practices and enhances the capacity of the public health system to provide needed patient care. See the section ‘BC Surgical and Diagnostic Imaging Strategy’ for data on the number of surgeries performed under HA contracts with private clinics.
BC confirms that False Creek Healthcare Centre has entered into contracts with two HAs, the Vancouver Coastal Health Authority (VCHA), for the period May 1, 2020, to March 31, 2023, and the Fraser Health Authority (FHA), for the period March 3, 2020, to March 31, 2023. For fiscal year 2020-2021, the contract is valued at $6.18 million consisting of $2.84 million from the FHA and $3.34 million from the VCHA. These contracts should eliminate extra- billing at False Creek Healthcare Centre, which has been a significant source of extra-billing in previous years.
In March 2018, the BC Surgical and Diagnostic Imaging Strategy (the strategy) was announced. The strategy aims to fulfil the mandate given by the Premier to the Health Minister to work to reduce wait times and increase access to publicly funded surgeries and diagnostic imaging procedures to benefit people in communities throughout the province. The strategy received
$100 million in targeted and ongoing funding in 2018-2019. Funding grew to $125 million in ongoing funding in 2019-2020 and $175 million in targeted funding in 2020-2021.
In 2019-2020 there were 255,936 scheduled surgeries performed in BC, a 6.5 percent increase over 2016-2017 when 234,814 scheduled surgeries were performed. The Ministry will be working with the HAs to quantify their increased public capacity so that we can better monitor in the future.
Key to achieving the mandate above is maximizing all the surgical capacity we have. In BC, as in other provinces, this includes private surgical centres. Contracting with these centres increases publicly funded access for patients whose surgical day procedures can be done safely and efficiently in the community, leaving our hospital capacity for more complex surgeries and procedures. Under contract arrangements with these clinics 12,336 surgeries were performed under contract in 2019-2020 - compared to 2018-2019 when 11,607 were performed. By negotiating contracts with private clinics to provide beneficiary services instead of extra- billing services BC has acted to prevent future extra-billing.
As an estimate of the impact, we would note that the Ministry has increased HA contracts, or extended additional contracts, to private surgical clinics found previously to be extra-billing. These contracts additions should eliminate an approximate equivalent in private billing. With these contracts, the HAs have moved from short term to multi-year terms of service (while maintaining termination clauses should extra-billing occur). The stability of these contract arrangements will keep former private capacity in the public system in a sustainable manner.
In addition to these steps, BC is also increasing public system capacity within HAs. This includes opening new operating rooms and extending the operating hours for others in our hospitals. In 2019-2020 operating rooms ran over 21,850 more hours than 2017-2018 and 30,597 more than in 2016-2017, the baseline year for the strategy. Additionally, in April 2022 the Province announced its purchase of View Royal Surgical Centre and Seafield Surgical Centre. These purchases resulted in an additional 2,300 surgeries and 2,300 endoscopies per year in the Island Health Authority. Through this strategy BC demonstrates its continued commitment to addressing patient extra-billing, as defined under the CHA.
With respect to medical imaging, in 2020-2021, BC conducted 247,106 MRI exams compared to 175,707 MRI exams in 2016-2017 and 189,520 in 2017-2018. This is a 41 percent increase since 2016-2017.
In 2020-2021, on average MRI operating hours were 4,343 per week. This is an increase of over 1,500 operating hours per week since August 2017. In 2017-2018 11 MRI units regularly operated for more than 112 hours per week, of these only one unit was operating on a 24/7 rotation. By the end of 2020-2021, 23 MRI units were regularly operating above 112 hours per week, of those, eight MRI units in growing urban areas were operating at a 24/7 staffing rotation.
This achievement was made by:
BC expects to make further gains in improving access through new MRI capacity that has been brought online. Since 2017, 17 net-new units became operational in BC, including:
These three outpatient MRI clinics were previously operating privately. In 2021-2022snapshot periods the Abbotsford MRI outpatient clinic operated up to 111 hours per week, the Surrey MRI outpatient clinic operated up to 86 hours per week and the Granville MRI outpatient clinic operated up to 112 hours per week. These completed exam volumes and added hours represent a direct reduction in the amount of private billing for diagnostic services in BC. As with surgical services, BC's approach to diagnostic services is redirecting previously private services to strengthen the public health care system.
At growing urban sites in Vancouver, Victoria and Surrey some of the newly added MRI units are the latest technology, they are state-of-the-art 3 Tesla (3T) MRI units which can perform scans more quickly, with no reduction in image quality and allow for quicker patient turnaround times. These are the first 3T units added within the province.
Health Human Resource (HHR) Strategy
Continued Improvements in Seniors Care, Long-Term Care and Assisted Living
Emergency Health Provider Registry (EHPR)
Supporting our Nursing and Allied Health Staff
Supporting Health Staff in BC's Northern Communities
Supporting Internationally Educated Health Professionals
New to Practice Incentives
Workplace Violence Prevention and Cultural Safety
Medically required laboratory services are publicly funded under the Laboratory Services Act (LSA). The Minister is responsible for all matters related to laboratory services including the facility approval process, governance, accountability and provision of benefits for all laboratory services in the province. The Agency for Pathology and Laboratory Medicine is now a program under the Provincial Health Services Authority (PHSA). The Agency's mandate is to provide laboratory system oversight and to ensure that clinical laboratory services are sustainable, quality driven, innovative, and support British Columbia's residents and clinicians with access to laboratory services. Since April 1, 2019 PHSA accepted accountability for operational functions assigned by the Ministry to support the LSA.
Following a competitive procurement process, Pacific Blue Cross Solutions (PBC Solutions) has been identified as the next Health Insurance BC (HIBC) service provider. The transition of HIBC services from the incumbent service provider (Maximus Canada) to PBC Solutions is scheduled for completion in Summer, 2023. Under the agreement, PBC Solutions will administer the province's Medical Service Plan, PharmaCare and laboratory programs and insurance plans (including responding to public inquiries, registering clients, and processing medical and pharmaceutical claims from health professionals). Policy and decision-making functions will continue to remain with the Ministry.
In 2017, Health Canada and the Ministry agreed upon a methodology to determine the extent and nature of patient extra-billing in BC, outlined in a Terms of Reference and Letter of Agreement. Since this agreement was put in place, the Ministry has completed ten audits of private surgical clinics, including Cambie. The results of these audits were shared with Health Canada in accordance with the agreement signed by our respective ministers in 2017.
In 2018-2019 further audits were put on hold to ensure the Ministry complied with the November 23, 2018, BC Supreme Court injunction prohibiting the enforcement of the extra-billing provisions (s. 17, 18, and 45 of the MPA).
Audits resumed in late 2020 with the final private surgery on site audits completed in late 2022, with one audit report still in the final review and sign-off stage. Since this agreement was put in place, the Ministry has completed twelve audits of private surgical clinics, including Cambie.
Starting in 2022-2023, for Health Canada reporting period 2020-2021, the Ministry will be required to report extra-billing attributed to private diagnostic facilities. A diagnostic audit framework is under development and the Ministry will commence audits of these facilities once S.18.1 of the MPA is enacted. Currently there are 12 private diagnostic facilities operating in BC. One of these facilities, False Creek Surgical Centre, was previously audited by the Ministry. The Ministry has plans to conduct three private diagnostic facility audits per year, until audits of the 11 remaining facilities have been completed.
The purpose of these audits is two-fold:
The Ministry will provide the final audit reports for individual clinics and/or providers to Health Canada subject to any redactions required to comply with the Freedom of Information and Personal Privacy Act. The Ministry is working through concerns and legalities around posting summarized versions of audit reports online. The Ministry will be adding communication resources for this work and recruitment to staff these positions will be undertaken in the short term. Their first order of priority will be to make sure this is completed and posted in a timely manner.
Subject to clarification from the Court, the Ministry is committed to full transparency and will continue to work with Health Canada in reviewing audit findings as the work is completed.
Monthly conference calls to discuss extra-billing and other pertinent matters including audit findings have been re-established.
BC is submitting a complete and accurate 2020-2021 extra-billing and user charges financial statement to Health Canada as per the reporting requirements set out in the CHA and Regulations. BC is reporting a total of $23,110,530.54 in extra-billing and user charges occurred in 2020-2021 according to the agreed-on reporting methodology.
In summary, BC is continuing to take all actions within its power to strengthen the public health care system, eliminate extra-billing, and ensure full compliance with CHA. The specific steps and strategies to reach that goal will evolve to address changing circumstances, but BC's multi- pronged and robust approach backed by significant resources will stay constant. By moving forward with the above noted actions, BC has taken the necessary steps to address extra-billing within the province and is seeking reimbursement from Health Canada for the 2020-2021 $23,110,530.54 million penalty.
BC has made significant efforts and incurred substantial expense to stop extra-billing over recent years, all within the legal parameters of the ongoing Cambie litigation and various forms of injunction that BC has been subject to.
Given the successful outcome of the Cambie litigation, ongoing efforts to educate and deter extra-billing, and a continued focus on audit and enforcement, we believe that this status update demonstrates BC's robust commitment to upholding the principles of the Canada Health Act under challenging circumstances, and we expect steps to be taken under the authority of the Federal reimbursement policy to reimburse BC for all extra-billing penalties levied to date, including any balance of Canada Health Transfer funds eligible for reimbursement previously withheld by the Federal Government and any penalty that may arise from the filing related to practices in effect in 2020-2021.
I attest that the above information captures the full extent of the Ministry of Health's efforts to eliminate extra-billing and ensure full compliance with the CHA and its Regulations and applicable provincial/territorial legislation.
December 13, 2022
Updated and resubmitted on February 15, 2023.
Rob Byers Assistant Deputy Minister, Ministry of Health British Columbia
Contact information is provided below for residents who believe they may have been subject to inappropriate patient charges for insured health services.
Refer to Chapter 1 for key definitions under the Canada Health Act. For detailed information on what health services are insured under provincial or territorial health insurance plans, refer to section 2.0- Comprehensiveness, under each provincial and territorial section.
Canada Health Act [email protected]
MCP General Inquiries Line 1-866-449-4459 (Avalon area) 1-800-563-1557 (all other regions)
Prince Edward Island Department of Health and Wellness P.O. Box 2000 Charlottetown, PEI C1A 7N8 1-902-368-6414
Department of Health and Wellness P.O. Box 488 Halifax, NS B3J 2R8
1-902-424-5818 1-800-387-6665 (toll-free in Nova Scotia) 1-800-670-8888 (TTY/TDD)
Medicare and Drug Plans
Covered services accessory costs
Commitment to the Future of Medicare Act Program [email protected]
Manitoba Health 300 Carlton Street Winnipeg, MB R3B 3M9 1-800-392-1207
Saskatchewan Ministry of Health [email protected]
Alberta Health Attention: Alberta Health Care Insurance Plan P.O. Box 1360, Stn Main Edmonton, AB T5J 2N3
1-780-427-1432 (Edmonton) 1-310-0000 then 780-427-1432 (toll-free in Alberta) 780-422-0102 (fax)[email protected]
Additional fees and charges
Yukon Medical Council [email protected] Medical Council Complaint Process
Health Services Administration Office, Health and Social Services Bag#9 Inuvik, NT X0E OTO 1-800-661-0830 1-867-777-7400 1-867-777-3197 (fax)
Nunavut Health Insurance Programs Office Department of Health Box 889 Rankin Inlet, NU X0C 0G0 1-800-661-0833 (toll free)[email protected]
https://www.ramq.gouv.qc.ca/en/citizens/health-insurance/medical-services
Return to footnote i referrer
This number excludes Ministry of Long-Term Care spending. On June 20, 2019, Ontario announced changes to its Cabinet that included the creation of the Ministry of Health and the Ministry of Long-Term Care. As such, the Ministry of Health and Long-Term Care will be referred to as the Ministry of Health (MOH) throughout this report.
Return to footnote ii referrer
https://www.auditor.on.ca/en/content/annualreports/arbyyear/ar2021.html
Return to footnote iii referrer
https://www.auditor.on.ca/en/content/annualreports/arreports/en21/AR_Cardiac_en21.pdf
Return to footnote iv referrer
https://www.auditor.on.ca/en/content/specialreports/specialreports/COVID-19_ch4mgmtexpenditures_en202105.pdf
Return to footnote v referrer
https://www.auditor.on.ca/en/content/specialreports/specialreports/COVID-19_ch5readinessresponseLTC_en202104.pdf
Return to footnote vi referrer
BC Ministry of Health. (2021, June 29). B.C. shifts to Step 3 of restart plan retrieved from https://news.gov.bc.ca/releases/2021PREM0043-001268
Return to footnote vii referrer
Note: where a practitioner has opted out of the MSP, medically required services are reimbursed directly to the beneficiary.
Return to footnote viii referrer
See section 2.1 for information on insured drugs, etc., for hospital in-patients and out-patients.
Return to footnote ix referrer
Contandriopoulos, D, K Bertoni and G.K. Randhawa 2022. Developmental Evaluation of NPPCCs. Interim report - September 2022.
Return to footnote x referrer
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Organization: Date published: Cat.: ISBN: Pub.: Insured health services Extended health care services Insured persons Insured hospital services Insured physician services Insured surgical-dental services The Canada Health Act Infographic Canada Health Act Infographic What is a patient charge? What is a Patient Charge? Infographic NB 6,886,000 QC 14,032,000 ON 106,656,000 MB 1,270,000 SK 2,107,000 AB 29,032,000 BC 84,749,000 TOTAL 85,961,000 106,365,000 52,406,000 244,732,000 Understanding This Chart NL NB QC ON BC Participating Physician or Dentist Non-Participating Physician or Dentist Opted-out Physician or Dentist Registered Persons: Insured Hospital Services within Own Province or Territory: Insured Hospital Services Provided to Residents in Another Province or Territory: Insured Hospital Services Provided Outside Canada: Insured Physician Services within Own Province or Territory: Insured Physician Services Provided to Residents in Another Province or Territory: Insured Physician Services Provided Outside Canada: Insured Surgical-Dental Services within Own Province or Territory: Public Facilities Private For-Profit Facilities Insured Hospital Services Provided to Residents in Another Province or Territory Insured Hospital Services Provided Outside Canada Pre-approved Non pre-approved Insured Physician Services Within Own Province or Territory Insured Physician Services Provided to Residents in Another Province or Territory Pre-approved Non pre-approved Vision: Mission: A. Hospital Insurance B. Medical Insurance Immigrants: Non-Canadians Refugees: Work Permits: Study Permits: The Office of the Auditor General: The Office of the Comptroller: Monitoring and Compliance Team: Residents: Mobile Workers: Contract Workers: Students: Stabilizing care: An Urgent Call to Action Fee for service: Mixed: Fixed fees Salary: Lump sum: Hourly rate: Supplements (incentive measures): Special incentive measures: Establishment laboratory service: Awareness-Raising Mechanisms Systematic Controls Specific Controls (inspections, investigations, service audits performed) Ontario Health Care and Health Care Planning Applicants for Permanent Residence: Protected Persons/Convention Refugees: Holders of Temporary Resident Permits: Foreign Clergy, Foreign Workers and their Accompanying Family Members: Applicants for Canadian Citizenship: Children Born Out-of-Country: Seasonal Agricultural Farm Workers: Holders of Emergency Authorizations Out-of-Province (Within Canada) Extended Absences: Primary Health Care: Interprofessional Care Models: Family Health Teams Nurse Practitioner-Led Clinics Community Health Centres Indigenous Primary Health Care Organizations (IPHCOs) ndigenous Primary Health Care Organizations (IPHCOs Health Care Connect Northern and Rural Recruitment and Retention Initiative (NRRRI): Northern Physician Retention Initiative (NPRI): Northern Health Travel Grant (NHTG) Program: Hospital Funding Sources Global funding: Growth and Efficiency Model (GEM) (Formerly Health-Based Allocation Model [HBAM]): HBAM Quality Based Procedures (QBP): Bundled Care: Priority Programs and Services: Post Construction Operating Plan (PCOP): Wait Times: Pay for Results (P4R): System Transformation Facilities Health Professionals Out-of-Province Out-of-Country Other Programs and Initiatives to Improve Access Attention: Phone: Fax: E-mail: Infrastructure and Capital Planning Physician services: Hospital services: Surgical-dental services: Children of Yukon residents born outside of Canada: Returning Canadians: Permanent Residents: Minister's Permit: Foreign Workers: Clergy: Extra-billing user charge CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 1,723.41 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges >$ NIL a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 0 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 0 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations. Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)). Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space as needed bellow. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. International and Intergovernmental Affairs Directorate CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 6,560 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. c) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. 21 Total # of Reviews Involving Confirmed EBUC (Including Facility Fees) Total Amount Charged and Reimbursed for Confirmed Reviews $19,474.49 $19,474.49 d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 0 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 0 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 0 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 13,275,823 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. Beneficiary and Diagnostic Services Branch: Audit and Investigation Branch, Billing Integrity Program: c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 0 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 0 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.Anywaysg., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. CANADA HEALTH ACT FINANCIAL STATEMENT OF ACTUAL AMOUNTS OF EXTRA-BILLING AND USER CHARGES FOR THE PERIOD APRIL 1, 2019 TO MARCH 31, 2020 Total for extra-billing and user charges $ 0.00 a) Name of applicable pieces of PT legislation that prohibit extra-billing and user charges (including facility fees). Please use as much space as needed below. b) Details about the process used to investigate extra-billing and user charges (e.g., proactive regular audits of provider billings; reactive investigations triggered by patient complaints, media reports or other sources). Please use as much space as needed below. c) A summary of any extra-billing and user charges investigations during the fiscal year including: Number of investigations Nature of each investigation (e.g., physician billing audits; patient triggered investigations; private clinic audits; third party report findings (e.g., Auditor General)) Confirmed cases and dollar amounts of extra-billing and user charges. Any amounts reimbursed to patients. Please use as much space needed bellow or add extra pages as necessary. d) Details on mechanisms to deter patient extra-billing and user charges (e.g., provider fines; plan payment withholding; provider/patient education initiatives; loss of facility accreditation). Please use as much space as needed below. [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.)] Public Administration Comprehensiveness Universality Portability Reasonable Accessibility Conditions Regulations [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.] [Following is the text of the letter sent on August 8, 2018, to all provincial and territorial Ministers of Health by the federal Minister of Health, the Honourable Ginette Petitpas Taylor.] Diagnostic Services Policy Reimbursement Policy Strengthened Reporting Reimbursement Policy for Provinces and Territories- Subject to Deductions under the Canada Health Act (the Reimbursement Policy) Background Time for a New Reimbursement Policy Current Process Working Together to Eliminate Patient Charges [Following is the text of the Newfoundland and Labrador Reimbursement Action Plan and January 2023 Status Update] [Following is the text of the Ontario's Reimbursement Action Plan and February 2023 Status Update] The timeline of the investigations The nature of the clinic-level service data requested by ON and provided by each clinic When the services described by this data were provided to patients The methodology used to analyze that data What was the nature of the fees charged by each clinic? How many patients were charged, and what proportion of patients at each clinic paid fees? Extra-billing and User Charges Patient information Summary Progress Report – Abortion Services in Ontario Action Timeline [Following is the text of the British Columbia Extra-Billing Elimination Action Plan and December 2022 Status Update] Health Human Resource (HHR) Strategy Continued Improvements in Seniors Care, Long-Term Care and Assisted Living Emergency Health Provider Registry (EHPR) Supporting our Nursing and Allied Health Staff Supporting Health Staff in BC's Northern Communities Supporting Internationally Educated Health Professionals New to Practice Incentives Workplace Violence Prevention and Cultural Safety