Health

CANADA HEALTH ACT
Public Administration / Comprehensiveness / Universality / Portability / Accessibility
2015 2016
Annual Report
Health Canada is the federal department responsible ACKNOWLEDGEMENTS
for helping the people of Canada maintain and improve
their health. We assess the safety of drugs and many Health Canada would like to acknowledge the work and
consumer products, help improve the safety of food, effort that went into producing this Annual Report. It is
and provide information to Canadians to help them make through the dedication and timely commitment of the
healthy decisions. We provide health services to First following departments of health and their staff that we
Nations people and to Inuit communities. We work with are able to bring you this report on the administration
the provinces to ensure our health care system serves and operation of the Canada Health Act:
the needs of Canadians.
Newfoundland and Labrador Department of Health and
Community Services
Également disponible en français sous le titre: Prince Edward Island Department of Health and Wellness
Loi canadienne sur la santé - rapport annuel 2015-2016
Nova Scotia Department of Health and Wellness
To obtain additional information, please contact:
New Brunswick Department of Health
Health Canada
Address Locator 0900C2 Quebec Ministry of Health and Social Services
Ottawa, ON K1A 0K9 Ontario Ministry of Health and Long-Term Care
Tel.: 613-957-2991 Manitoba Health, Seniors and Active Living

Toll free: 1-866-225-0709
Fax: 613-941-5366 Saskatchewan Health
TTY: 1-800-465-7735
Alberta Health
E-mail: publications@hc-sc.gc.ca British Columbia Ministry of Health
This publication can be made available in alternative Yukon Health and Social Services
formats upon request.
Northwest Territories Department of Health and Social
© Her Majesty the Queen in Right of Canada, as Services
represented by the Minister of Health, 2016
Nunavut Department of Health
Publication date: February 2017
We also greatly appreciate the extensive work effort that
This publication may be reproduced for personal or was put into this report by our production team: the desk-
internal use only without permission provided top publishing company, the translators, editors and con-
the source is fully acknowledged. cordance experts, printers and staff of Health Canada.
PRINT Cat.:H1-4E
ISSN: 0842-3202
PDF Cat.: H1-4E-PDF

ISSN: 1497-9144
Pub.: 160145
TA BL E O F C O N TE N T S
Acknowledgements inside front cover
PREFACE 4
INTRODUCTION 6
CHAPTER 1: Canada Health Act Overview 7
CHAPTER 2: Administration and Compliance 15
CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2015-2016 22
Newfoundland and Labrador 24
Prince Edward Island 34
Nova Scotia 41
New Brunswick 51
Quebec 60
Ontario 66
Manitoba 78
Saskatchewan 88
Alberta 97
British Columbia 105
Yukon 116
Northwest Territories 126
Nunavut 133
ANNEX A: Canada Health Act and Extra-Billing and User Charges Information Regulations 141
ANNEX B: Policy Interpretation Letters 163
ANNEX C: Dispute Avoidance and Resolution Process under the Canada Health Act 171
Contact Information for Provincial and Territorial Departments of Health inside back cover
CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 3

PRE FAC E
I am honoured to present the Canada Health Act Annual Report
2015-2016 to Parliament and to Canadians. Having worked as
a physician for close to thirty years, I firmly believe that the
foundational strength of our health care system rests on the
principles enshrined in the Canada Health Act. Now, as Federal
Minister of Health, one of my key responsibilities is to uphold
the Act, which ensures all Canadians have equitable access to
essential health care services based on their need and not their
ability, or willingness, to pay.
The Canada Health Act is not simply a piece of legislation, This quote, although relevant in the current context, is
it also articulates what we believe as Canadians and drawn from a letter from one of my predecessors, the
embodies our notions of fairness and equity. When Honourable Diane Marleau, to her provincial and
Parliament passed the Canada Health Act in 1984, it was territorial colleagues, in 1995. At the time, the publicly
one of the few pieces of legislation ever that was unan- funded health care system was threatened by the
imously approved by all federal parties. I like to think this proliferation of private clinics charging insured residents
was the case because we all recognize that every person out-of-pocket for insured services. I agree with Minister
deserves the opportunity for health – which in turn enables Marleau that such charges are contrary to the Canada
other opportunities in life. Before Medicare, in addition Health Act. I believe that when Canadians pay for their
to the anxieties that medical issues can bring, families health services through their tax dollars, they should not
also worried about the debt they were accumulating as be asked to pay again when they access those services,
they sought care. I am grateful that during my time as a in the form of user fees. Not only do these fees constitute
family physician, I never had to turn away a patient who extra-billing and user charges under the Act, they pose
needed medical care on the grounds that they lacked the concerns under the accessibility criterion, since insured
means to pay for it. I am committed to doing everything residents no longer have access to insured services on
I can to ensure that an accessible health care system is uniform terms and conditions when some can choose to
in place for our collective future. pay for expedited access.
“The principles set out in the Act (public administration, With that in mind, on March 31, 2016, the Attorney General
comprehensiveness, universality, portability and acces- of Canada, on my recommendation, gave notice that
sibility) continue to enjoy the support of all provincial Canada would appear as a party in the Cambie Surgeries
Corporation et al. v. Medical Services Commission et al.
and territorial governments. This support is shared by
litigation, before the British Columbia Supreme Court.
the vast majority of Canadians. At a time when there is The plaintiffs want the court to strike down provisions of
concern about the potential erosion of the publicly British Columbia’s Medicare Protection Act that prohibit
funded and publicly administered health care system, user charges, extra-billing and private insurance for health
it is vital to safeguard these principles.” services covered under British Columbia’s provincial
health care insurance plan. Canada is assisting British
4
Columbia in this case by making arguments in support ance with the principles of the Act so that Canadians
of the constitutionality of provisions of the Medicare have access to the care they need, when they need it.
Protection Act, which reflect the principles of the Canada As my consultations with these provinces are ongoing,
Health Act and discourage the development of a two-tier I will provide more details on these issues in the next
system of medicine. We are participating in the case not Canada Health Act Annual Report.
just because of the implications for insured health ser-
vices in British Columbia, but because the decision in In the years since it was passed, the Canada Health Act
this case will have broad implications for the future of has come to be regarded by many as a symbol of what
our publicly funded health care system. We simply cannot it means to be Canadian.
return to a system where Canadian residents receive
different levels of care, depending on their financial
circumstances. I spent nearly a decade of my career as a physician in
West Africa and I am often reminded of a saying from
In the years since it was passed, the Canada Health Act Niger which, translated to English, says that health is
has come to be regarded by many as a symbol of what the mother of everything and without our health, we
it means to be Canadian. Canadians continue to support have nothing. As a physician, I have seen firsthand the
the principles of the Canada Health Act, as do provin- difference that access to care makes in individual lives.
cial and territorial governments, whose health insurance As Federal Minister of Health, I believe that access to
legislation mirrors the principles and requirements of health care is of the utmost importance not just to our
the Act. When issues of concern arise, my approach personal success as individuals but to our collective
is to seek compliance with the Act in an environment success as a nation. While the Canada Health Act is over
of collegiality, and in a manner that is fair, even-handed 30 years old, the values that underpin the Act and its
and consistent across the country. For that reason, over principles, those of equity, fairness and solidarity, are
the past year I have engaged my counterparts in British just as relevant today as they were in 1984, and they will
Columbia, Saskatchewan and Quebec to communicate remain relevant as we continue to improve our health
my concerns about extra-billing and user charges being care system to meet the needs of Canadians.
levied in those provinces. My ultimate goal is not to levy
penalties as a punitive measure but to ensure compli- -The Honourable Jane Philpott, Minister of Health

I NT RO D U CT I O N
Canada has a predominantly publicly financed The roles and responsibilities for Canada’s health care
and administered health care system. The system are shared between the federal, provincial and
territorial governments. The provincial and territorial
Canadian health insurance system is achieved
governments have primary jurisdiction in the administra-
through 13 interlocking provincial and territorial tion and delivery of health care services. This includes
health care insurance plans, and is designed to setting their own priorities, administering their health
ensure that all eligible residents of Canadian care budgets and managing their own resources. The fed-
provinces and territories have reasonable access eral government, under the Canada Health Act, sets out
the criteria and conditions that must be satisfied by the
to medically necessary hospital and physician
provincial and territorial health care insurance plans for
services on a prepaid basis, without charges re- provinces and territories to qualify for their full share of
lated to the provision of insured health services. the cash contribution available to them under the federal
Canada Health Transfer.
On an annual basis, the Federal Minister of Health is

The Canadian health insurance system evolved into its required to report to Parliament on the administra-
present form over more than six decades. Saskatchewan tion and operation of the Canada Health Act, as set
was the first province to establish universal, public out in section 23 of the Act. The vehicle for so doing
hospital insurance in 1947 and, ten years later, the is the Canada Health Act Annual Report. While the
Government of Canada passed the Hospital Insurance principal and intended audience for the annual report is
and Diagnostic Services Act (1957), to share in the cost Parliamentarians, it is a public document that offers a
of these services with the provinces and territories. comprehensive description of insured health services in
By 1961, all the provinces and territories had public each of the provinces and territories. The Annual Report
insurance plans that provided universal access to hospital is structured to address the mandated reporting require-
services. Saskatchewan again pioneered by providing ments of the Act; as such, its scope does not extend
insurance for physician services, beginning in 1962. The to commenting on the status of the Canadian health
Government of Canada enacted the Medical Care Act in care system as a whole.
1966 to cost-share the provision of insured physician
services with the provinces and territories. By 1972, Provincial and territorial health care insurance plans gen-
all provincial and territorial plans had been extended to erally respect the criteria and conditions of the Canada
include physician services. Health Act and many exceed the requirements of the
Act. However, when instances of possible non-compliance
In 1979, at the request of the federal government, with the Act arise, Health Canada’s approach to the
Justice Emmett Hall undertook a review of the state of administration of the Act emphasizes transparency, con-
health services in Canada. In his report, he affirmed that sultation and dialogue with provincial and territorial
health care services in Canada ranked among the best health care ministries. Health Canada’s goal is not to levy
in the world, but warned that extra-billing by doctors and penalties as a punitive measure but to ensure compli-
user charges levied by hospitals were creating a two- ance with the principles of the Canada Health Act so
tiered system that threatened the universal accessibility that Canadians have access to the health care they
of care. This report, and the national debate it generated, need, when they need it.
led to the enactment of the Canada Health Act in 1984.
The Canada Health Act is Canada’s federal health care

insurance legislation and defines the national principles
that govern the Canadian health care insurance system,
namely, public administration, comprehensiveness, univer-
sality, portability and accessibility. These principles reflect
the underling Canadian values of equity and solidarity.
6
CHAPTER 1 | CANADA HEALTH ACT OVERVIEW
CA NA DA H E ALT H AC T OV E RV IE W
This section describes the Canada Health Act, province, but does not include a tourist, a transient or a
its requirements, key definitions, Regulations and visitor to the province.”
letters by former Federal Ministers of Health Jake Persons excluded under the Act include serving
Epp and Diane Marleau to their provincial and members of the Canadian Forces and inmates of federal
territorial counterparts that are used in the inter- penitentiaries.
pretation and application of the Act, and the letter
Insured health services are medically necessary hospi-
from former Federal Minister, A. Anne McLellan, tal, physician and surgical-dental services (performed by
to her provincial and territorial counterparts on a dentist in a hospital, where a hospital is required for
the Canada Health Act Dispute Avoidance and the proper performance of the procedure) provided to
Resolution process. A history of the evolution of insured persons.
federal health care transfers follows. Insured hospital services are defined under the Act and
include medically necessary in- and out-patient services
such as accommodation and meals at the standard or
public ward level and preferred accommodation if medi-
What is the Canada cally required; nursing service; laboratory, radiological
and other diagnostic procedures, together with the nec-
Health Act? essary interpretations; drugs, biologicals and related
preparations when administered in the hospital; use of
The Canada Health Act is Canada’s federal legislation operating room, case room and anaesthetic facilities,
for publicly funded health care insurance. The Act sets including necessary equipment and supplies; medical
out the primary objective of Canadian health care policy, and surgical equipment and supplies; use of radiothera-
which is “to protect, promote and restore the physical py facilities; use of physiotherapy facilities; and services
and mental well-being of residents of Canada and to provided by persons who receive remuneration therefor
facilitate reasonable access to health services without from the hospital.
financial or other barriers.”
Insured physician services are defined under the Act as
The Act establishes criteria and conditions related “medically required services rendered by medical practi-
to insured health services and extended health care tioners.” Medically required physician services are gener-
services that the provinces and territories must fulfill ally determined by the provincial or territorial health care
to receive the full federal cash contribution under the insurance plan, in conjunction with the medical profession.
Canada Health Transfer (CHT).
Insured surgical-dental services are services provided
The aim of the Act is to ensure that all eligible residents by a dentist in a hospital, where a hospital setting is
of Canadian provinces and territories have reasonable required to properly perform the procedure.
access to medically necessary hospital and physician
services on a prepaid basis, without charges related to Extended health care services, as defined in the Act,
the provision of insured health 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
KEY DEFINITIONS UNDER THE ambulatory care services.
CANADA HEALTH ACT Requirements of the Canada Health Act
Insured persons are eligible residents of a province or The Canada Health Act contains nine requirements
territory. A resident of a province is defined in the Act as that the provinces and territories must fulfill in order to
“a person lawfully entitled to be or to remain in Canada qualify for the full amount of their cash entitlement
who makes his home and is ordinarily present in the under the CHT.

They are: or territory of residence. It is the responsibility of residents

to inform their province or territory’s health care insurance
• five program criteria that apply only to insured health plan that they are leaving and to register with the health
services; care insurance plan of their new province or territory.
• two conditions that apply to insured health services Residents who are temporarily absent from their home
and extended health care services; and province or territory or from Canada, must continue to be
covered for insured health services during their absence.
•
extra-billing and user charges provisions that apply
If insured persons are temporarily absent in another prov-
only to insured health services.
ince or territory, the portability criterion requires that
insured services be paid at the host province’s rate. If
THE CRITERIA insured persons are temporarily out of the country, insured
services are to be paid at the home province’s rate.
1. Public Administration (section 8)
The public administration criterion requires provincial The portability criterion does not entitle a person to seek
and territorial health care insurance plans to be services in another province, territory or country, but is in-
administered and operated on a non-profit basis by a tended to permit a person to receive necessary services
public authority, which is accountable to the provincial in relation to an urgent or emergent need when absent
or territorial government for decision-making on benefit on a temporary basis, such as on business or vacation.
levels and services, and whose records and accounts Prior approval by the health care insurance plan in a
are publicly audited. However, the criterion does not person’s home province or territory may be required
prevent the public authority from contracting out the before coverage is extended for elective (non-emergency)
services necessary for the administration of the provin- services to a resident while temporarily absent from
cial and territorial health care insurance plans. their province or territory.
The public administration criterion pertains only to the 5. Accessibility (section 12)
administration of provincial and territorial health care The intent of the accessibility criterion is to ensure that
insurance plans and does not preclude private facilities insured persons in a province or territory have reasonable
or providers from supplying insured health services access to insured hospital, medical and surgical-dental
as long as no insured person is charged in relation to services on uniform terms and conditions, unprecluded
these services. or unimpeded, either directly or indirectly, by charges
2. Comprehensiveness (section 9) (extra-billing or user charges) or other means (e.g., dis-
The comprehensiveness criterion of the Act requires crimination on the basis of age, health status or financial
that the health care insurance plan of a province or circumstances).
territory must cover all insured health services provided Reasonable access in terms of physical availability of
by hospitals, physicians or dentists (i.e., surgical-dental medically necessary services has been interpreted
services that require a hospital setting). under the Canada Health Act using the “where and as
3. Universality (section 10) available” rule. Thus, residents of a province or territory
Under the universality criterion, all insured residents of are entitled to have access on uniform terms and condi-
a province or territory must be entitled to the insured tions to insured health services at the setting “where”
health services provided by the provincial or territorial the services are provided and “as” the services are
health care insurance plan on uniform terms and con- available in that setting.
ditions. Provinces and territories generally require that In addition, the health care insurance plans of the pro-
residents register with the plan to establish entitlement. vince or territory must provide:
4. Portability (section 11) • reasonable compensation to physicians and dentists
Residents moving from one province or territory to an- for all the insured health services they provide; and
other must continue to be covered for insured health
services by the “home” jurisdiction during any waiting •
payment to hospitals to cover the cost of insured
period (up to three months) imposed by the new province health services.
8
THE CONDITIONS government to make regulations for administering the

Act in the following areas:
1. Information (section 13(a))
The provincial and territorial governments are required • defining the services included in the Act’s definition of
to provide information to the Federal Minister of Health “extended health care services,” e.g., nursing home
as prescribed by regulations under the Act. care or home care;
2. Recognition (section 13(b)) • prescribing which services are excluded from hospital
The provincial and territorial governments are required services;
to recognize the federal financial contributions toward
• prescribing the types of information that the Federal
both insured and extended health care services.
Minister of Health may reasonably require, as well as
the format and submission deadline for the information;
EXTRA-BILLING AND USER CHARGES and
The provisions of the Canada Health Act pertaining • prescribing how provinces and territories are required
to extra-billing and user charges for insured health to recognize the CHT in their documents, advertising
services in a province or territory are outlined in sections or promotional materials.
18 to 21. If it can be confirmed that either extra-billing or To date, the only regulations in force under the Act
user charges exist in a province or territory, a mandatory are the Extra-billing and User Charges Information
dollar-for-dollar deduction from the federal cash transfer Regulations. These Regulations require the provinces and
to that province or territory is required under the Act. territories to annually report to Health Canada amounts
Extra-billing (section 18) of extra-billing and user charges levied. A copy of these
Under the Act, extra-billing is defined as the billing Regulations is provided in Annex A.
for an insured health service rendered to an insured
person by a medical practitioner or a dentist (i.e.,
a dentist providing insured surgical-dental services in a
PENALTY PROVISIONS OF THE
hospital setting) in an amount in addition to any amount CANADA HEALTH ACT
paid or to be paid for that service by the health care
insurance plan of a province or territory. For example, if Mandatory Penalty Provisions
a physician was to charge a patient any amount for an Under the Act, provinces and territories that allow extra-
office visit that is insured by the provincial or territorial billing and user charges are subject to mandatory dollar-
health care insurance plan, the amount charged would for-dollar deductions from the federal transfer payments
constitute extra-billing. Extra-billing is seen as a barrier under the CHT. For example, this means that when it
or impediment for people seeking medical care, and is has been determined that a province or territory has
therefore also contrary to the accessibility criterion. allowed any amount in extra-billing by physicians, the
federal cash contribution to that province or territory will
User Charges (section 19) be reduced by that same amount. The amount of such a
The Act defines user charges as any charge for an insured deduction for a fiscal year is determined by the Federal
health service, other than extra-billing. For example, if Minister of Health. Although it is usually based on informa-
patients were charged a facility fee for the non-physician tion provided by the province or territory in accordance
(i.e., hospital) services provided at a clinic, that fee would with the Extra-billing and User Charges Information
be considered a user charge. User charges are not permit- Regulations (described below), Section 20 of the Act
ted under the Act because, as is the case with extra-billing, requires the Minister to make an estimate of the amount
they constitute a barrier or impediment to access. of extra-billing and user charges where information is
not provided in accordance with the Regulations. This
process requires the Minister to consult with the province
OTHER ELEMENTS OF THE ACT or territory concerned.
Regulations (section 22) Discretionary Penalty Provisions

Section 22 of the Canada Health Act enables the federal Non-compliance with one of the five criteria or two

conditions of the Act is subject to a discretionary penalty. Excluded Persons

The amount of any deduction from federal transfer The Canada Health Act definition of “insured person”
payments under the CHT is based on the magnitude of excludes members of the Canadian Forces and persons
the non-compliance. serving a term of imprisonment within a federal peniten-
tiary. The Government of Canada provides coverage to
The Canada Health Act sets out a consultation process that these groups through separate federal programs.
must be undertaken with the province or territory before
discretionary penalties can be levied. To date the discretion- The exclusion of these persons from insured health
ary penalty provisions of the Act have not been applied. service coverage predates the adoption of the Act and
is not intended to constitute differences in access to
publicly insured health care.
EXCLUDED SERVICES AND PERSONS
Although the Canada Health Act requires that insured POLICY INTERPRETATION LETTERS
health services be provided to insured persons in a
manner that is consistent with the criteria and conditions There are two key policy statements that clarify the
set out in the Act, not all health services or Canadian federal position on the Canada Health Act. These state-
residents fall under the scope of the Act. ments were made in the form of ministerial letters from
former Federal Ministers of Health to their provincial and
Excluded Services territorial counterparts. Both letters are reproduced in
A number of services provided by hospitals and physi- Annex B of this report.
cians are not considered medically necessary, and thus
are not insured under provincial and territorial health Epp Letter
care insurance legislation. Uninsured hospital services In June 1985, approximately one year following the
for which patients may be charged include preferred hos- passage of the Canada Health Act in Parliament,
pital accommodation unless prescribed by a physician or Federal Minister of Health and Welfare Jake Epp wrote
when standard ward level accommodation is unavailable, to his provincial and territorial counterparts to set out and
private duty nursing services and the provision of tele- confirm the federal position on the interpretation and
phones and televisions. Uninsured physician services implementation of the Act
for which patients may be charged include telephone
advice; the provision of medical certificates required Minister Epp’s letter followed several months of consulta-
for work, school, insurance purposes and fitness clubs; tion with his provincial and territorial counterparts. The
testimony in court; and cosmetic services. letter sets forth statements of federal policy intent that
clarify the Act’s criteria, conditions and regulatory provi-
In addition, the definition of “insured health services” sions. These clarifications have been used by the federal
excludes services to persons provided under any other government in assessing and interpreting compliance
Act of Parliament (e.g., certain services provided to vet- with the Act. The Epp letter remains an important refer-
erans) or under the workers’ compensation legislation of ence for interpreting the Act.
a province or territory.
Marleau Letter - Federal Policy on Private Clinics
In addition to the medically necessary hospital and physi- Between February 1994 and December 1994, a series
cian services covered by the Canada Health Act, provinces of seven federal/provincial/territorial meetings dealing
and territories also provide a range of other programs wholly, or in part, with private clinics took place. At issue
and services. These are provided at provincial and terri- was the growth of private clinics providing medically
torial discretion, on their own terms and conditions, and necessary services funded partially by the public system
vary from one province or territory to another. Additional and partially by patients, and their impact on Canada’s
services that may be provided include pharmacare, am- universal, publicly funded health care system.
bulance services and optometric services. The additional
services provided by provinces and territories are often At the September 1994 federal/provincial/territorial meet-
targeted to specific population groups (e.g., children, ing of health ministers in Halifax, all ministers of health
seniors or social assistance recipients), and may be present, with the exception of Alberta’s health minister,
partially or fully covered by the province or territory. agreed to “take whatever steps are required to regulate
the development of private clinics in Canada.”
10
Diane Marleau, the Federal Minister of Health at the EVOLUTION OF FEDERAL HEALTH
time, wrote to all provincial and territorial ministers of
health on January 6, 1995, to announce the new Federal CARE TRANSFERS
Policy on Private Clinics. The Minister’s letter provided Grants to Help Establish Programs and Cost-Sharing
the federal interpretation of the Canada Health Act as Federal support for provincial health care goes back to
it relates to the issue of facility fees charged directly to the late 1940s when the National Health Grants were
patients receiving medically necessary services at private created. These grants were considered to be essential
clinics. The letter stated that the definition of “hospital” building blocks of a national health care system. While
contained in the Act includes any public facility that pro- the grants were mainly used to build up the Canadian
vides acute, rehabilitative or chronic care. Thus, when a hospital infrastructure, they also supported initiatives
provincial or territorial health care insurance plan pays in areas such as professional training, public health
the physician fee for a medically necessary service research, tuberculosis control and cancer treatment.
delivered at a private clinic, it must also pay the facility By the mid-1960s, the grants available to the provinces
fee or face a deduction from federal transfer payments. totaled more than $60 million annually.
In the mid-1950s in response to public pressures, the

DISPUTE AVOIDANCE AND federal government agreed to provide financial assistance
RESOLUTION PROCESS to provinces to help them establish health insurance pro-
grams. In January 1956, the federal government placed
In April 2002, Federal Minister of Health A. Anne McLellan concrete proposals before the provinces to inaugurate a
outlined in a letter to her provincial and territorial coun- phased health insurance program, with priority given to
terparts a Canada Health Act Dispute Avoidance and hospital insurance and diagnostic services. Discussions
Resolution process, which was agreed to by provinces on these proposals led to the adoption of the Hospital
and territories, except Quebec. The process meets Insurance and Diagnostic Services Act (HIDSA) in 1957.
federal and provincial or territorial interests of avoiding The implementation of the HIDSA started in July 1958,
disputes related to the interpretation of the principles by which time Newfoundland, Saskatchewan, Alberta,
of the Act and, when this is not possible, resolving British Columbia and Manitoba were operating hospital
disputes in a fair, transparent and timely manner. insurance plans. By 1961, all provinces and territories
were participating in the program.
The process includes the dispute avoidance activities of
government-to-government information exchange; dis- The second phase of the federal intervention supporting
cussions and clarification of issues as they arise; active provincial and territorial health insurance programs resulted
participation of governments in ad hoc federal/provincial/ from the recommendations of the Royal Commission on
territorial committees on Act-related issues; and Canada Health Services (Hall Commission). In its final report,
Health Act advance assessments, upon request. tabled in 1964, the Hall Commission recommended
establishing a new program that would ensure that all
Where dispute avoidance activities prove unsuccessful, dis- Canadians have access to necessary medical care (phy-
pute resolution activities may be initiated, beginning with sician services, outside a hospital setting).
government-to-government fact-finding and negotiations. If
these are unsuccessful, either minister of health involved The Medical Care Act was introduced in Parliament in
may refer the issues to a third-party panel to undertake July 1966, and received Royal Assent on December 21,
fact-finding and provide advice and recommendations. 1966. The implementation of the medical care program
started on July 1, 1968. By 1972, all provinces and
The Federal Minister of Health has the final authority territories were participating in the program.
to interpret and enforce the Canada Health Act. In de-
ciding whether to invoke the non-compliance provisions Originally, the federal government’s method of contrib-
of the Act, the Minister will take the panel’s report into uting to provincial and territorial hospital insurance
consideration. programs was based on the cost to provinces and
territories of providing insured hospital services. Under
A copy of Minister McLellan’s letter is included in Annex the HIDSA, the federal government reimbursed the
C of this report. provinces and territories for approximately 50 per cent

of the costs of hospital insurance. In both cases, funding a virtually unconditional basis and, unlike the insured
was conditional on certain program criteria being met. services transfer, was not subject to specified program
Under the Medical Care Act, the federal contribution delivery criteria.
was set at 50 per cent of the average national per capita
costs of the insured services, multiplied by the number Under the prevailing legislative framework, the
of insured persons in each province and territory. Funding Government of Canada was required to withhold all of
protocols based on conditional grants continued until the the monthly health care transfer to a province or territory
move to block funding was made in fiscal year 1977-1978. for each month the program delivery criteria were not
met. It was not until the enactment of the Canada Health
Act in 1984 that deduction provisions came into force
ESTABLISHED PROGRAMS allowing for dollar-for-dollar deductions for extra-billing
and user charges, and discretionary deductions when
FINANCING provincial and territorial plans failed to fully comply with
On April 1, 1977, federal funding supporting insured other provisions set out in the Act.
health care services was replaced by a block fund
transfer with only general requirements related to
maintaining a minimum standard of health services
CANADA HEALTH AND
through the passage of the Federal-Provincial Fiscal SOCIAL TRANSFER
Arrangements and Established Programs Financing Act,
1977. Known also as the EPF Act, the new legislation In the 1995 Budget, the federal government announced
provided federal contributions to the provinces and a restructuring of the EPF Act, from then on to be called
territories for insured hospital and medical care services the Federal-Provincial Fiscal Arrangements Act, with pro-
(as well as for post-secondary education) that were no visions for a Canada Health and Social Transfer (CHST),
longer tied to provincial expenditures. Rather, federal for the purpose of maintaining the national criteria and
contributions made in fiscal year 1975-1976 under the conditions of the Canada Health Act, including the Act’s
existing cost-sharing programs were designated as provisions relating to extra-billing and user charges.
the base year for contributions, to be escalated by the
The new omnibus or block transfer, beginning in fiscal
rate of growth of nominal Gross National Product and
year 1996-1997, merged the health and post-secondary
increases to the population.
education funding of the EPF Act with Canada Assistance
Under the EPF Act and subsequent funding arrange- Plan funding (the federal/provincial cost-sharing arrange-
ments, the total amount of the provincial and territorial ment for social services). When the CHST came into effect
health care entitlement was made up of relatively equal on April 1, 1996, provinces and territories received CHST
cash and tax transfers. The federal tax transfer involves cash and tax transfer in lieu of entitlements under the
the federal government ceding some of its “tax room” Canada Assistance Plan (CAP) and EPF. The new CHST
to the provincial and territorial governments, reducing cash amount provided to provinces and territories was
its tax rate to allow provinces to raise their tax rates by less than the combined values of EPF and CAP, reflecting
an equivalent amount. With the Established Programs the need for fiscal restraint at the time the CHST was
Financing “health” tax transfer, the changes in federal and introduced. The 1995 and 1996 Budget legislation provided
provincial tax rates offset one another, meaning there for total CHST amounts (cash and tax transfers) for sub-
was no net impact on taxpayers. The total amount of the sequent years, with an annual floor of $11 billion for the
health care entitlement did not change. cash component to apply until 2002-2003.
The EPF Act also included a new transfer for the The Federal-Provincial Fiscal Arrangements Act also
Extended Health Care Services Program. This group of transferred the cash payment authority from Health
health care services, defined as nursing home interme- Canada to the Department of Finance. However, the
diate care, adult residential care, ambulatory health care Federal Minister of Health continued to be responsible for:
and the health aspects of home care, were block funded
•
recommending the amounts of any deductions or
on the basis of $20 per capita for fiscal year 1977-1978,
withholdings pursuant to the conditions and criteria of
and subject to the same escalator as insured health
the Act to the Governor in Council;
services. This portion of the EPF transfer was made on
12
• determining the amounts of any deductions pursuant Transfer (CST), effective April 1, 2004. The CHT supports
to the extra-billing and user charges provisions of the the Government of Canada’s ongoing commitment to
Act; and maintain the national criteria and conditions of the
Canada Health Act. The CST, a block fund that supports
• ensuring that these amounts are communicated to the post-secondary education and social assistance and
Department of Finance before the CHST payment dates. social services, continues to give provinces and
territories the flexibility to allocate funds among these
From 1997 to 2000, there were several increases to the
social programs according to their respective priorities.
cash portion of the CHST, including increases to the
cash floor. In 1998, the cash floor was increased to $12.5 The existing CHST-legislated amounts were apportioned
billion. With the federal government’s return to surpluses, between the new transfers, with the percentage of
Budget 1999 announced an additional $11.5 billion for cash and tax points allocated to each transfer reflecting
health care. Of this amount, $8 billion was provided in provincial and territorial spending patterns among the
CHST cash over the following four years. The remaining areas supported by the transfers: 62 per cent for the CHT
$3.5 billion was provided through a trust fund notionally and 38 per cent for the CST.
allocated over three years to provide provinces and
territories flexibility over when to draw down the funds. 2004 10-year Plan to Strengthen Health Care
Budget 2000 then provided an additional $2.5 billion for Federal transfers to the provinces and territories were fur-
health care through another trust fund to provinces and ther increased as a result of the 10-Year Plan to Strengthen
territories, notionally allocated over four years. Health Care. Signed by all First Ministers on September
16, 2004, this initiative committed the Government of
2000 and 2003 Health Accords: Increasing and Re- Canada to an additional $41.3 billion in funding, over ten
structuring Federal Support for Health years until 2013-2014, to the provinces and territories for
In 2000 and 2003, First Ministers met to discuss health health. This included $35.3 billion in increases to the CHT,
care, focusing on reform, reporting and funding require- $5.5 billion in Wait Times Reduction funding, and $500
ments. In 2000, the federal government announced million in support of diagnostic and medical equipment.
$23.4 billion in new spending over five years on health
care renewal and early childhood development. This Budget 2007
included an additional $21.1 billion in increases to the Budget 2007 put all major transfers on a long-term,
CHST cash contributions, as well as an additional $1.8 principles-based track to 2013-2014. In order to provide
billion for targeted programs (medical equipment and comparable treatment for all Canadians regardless of
primary health care reform), and $500 million for Canada where they live, the budget legislated equal per capita
Health Infoway. cash support for the CST, starting in 2007-2008, and the
CHT, starting after the 10-Year Plan to Strengthen Health
In 2003, the government committed $36.8 billion over Care concluded in 2013-2014. In addition, Budget 2007
five years to support priority areas of health reform invested an additional $1 billion to help provinces and
(primary care, home care and catastrophic drugs). This territories introduce wait time guarantees, including
was provided through $14 billion in increased CHST initiatives delivered through Canada Health Infoway.
transfers and $16 billion for the Health Reform Transfer,
as well as $1.5 billion for medical equipment. This was in Current Transfer Levels
addition to $5.3 billion in federal direct spending on health As announced by the Government of Canada in
information technologies, Aboriginal health initiatives, December 2011, and legislated in the Jobs, Growth and
patient safety and other health-related federal initiatives. Long-term Prosperity Act, the CHT will continue to grow
at an annual rate of six per cent for an additional three
The federal government also agreed to restructure the years beyond 2013-2014 (i.e., until 2016-2017). Starting
CHST to enhance the transparency and accountability of in 2017-2018, the CHT will grow in line with a three-year
federal support for health. moving average of nominal gross domestic product
growth, with funding guaranteed to increase by at least
three per cent per year.
THE CANADA HEALTH TRANSFER
The CHST was restructured into two new transfers, the
Canada Health Transfer (CHT) and the Canada Social

Following up on the 2007 legislation for a transition to an

equal per capita cash allocation for the CHT in 2014-2015,
the Jobs, Growth and Long-term Prosperity Act ensured
a fiscally responsible transition by providing protection
so that no province or territory will receive less than its
2013-2014 CHT cash allocation in subsequent years as a
result of the move to equal per capita cash.
Additional information on federal-provincial-territorial

funding arrangements is available upon request from
the Department of Finance, or by visiting its website
at: Federal Support to Provinces and Territories - Major
Federal Transfers at: https://www.fin.gc.ca/access/
fedprov-eng.asp.
14
CHAPTER 2 | ADMINISTRATION AND COMPLIANCE
AD MI N I ST RAT I ON A N D C OMP L IA N CE
Administration • informing the Federal Minister of Health of possible

non-compliance and recommending appropriate action
In administering the Canada Health Act (CHA), the Federal to resolve the issue; and
Minister of Health is assisted by Health Canada staff and
• working with Health Canada Legal Services and Justice
by the Department of Justice.
Canada on litigation issues that implicate the CHA.
THE CANADA HEALTH ACT DIVISION INTERPROVINCIAL HEALTH

The Canada Health Act Division of Health Canada is re- INSURANCE AGREEMENTS
sponsible for administering the CHA. Members of the
Division fulfill the following ongoing functions:
COORDINATING COMMITTEE
The Interprovincial Health Insurance Agreements
• monitoring and analyzing provincial and territorial health
Coordinating Committee (IHIACC) was formed in 1991 to
care insurance plans for compliance with the criteria,
address issues affecting the interprovincial billing of
conditions, and extra-billing and user charges provi-
insured hospital and physician services. The Committee
sions of the CHA;
includes members from each province and territory and
• disseminating information on the CHA; a non-voting chair from the Canada Health Act Division.
The Canada Health Act Division also provides secretariat
• responding to enquiries about the CHA and health insur- functions for IHIACC.
ance issues received by telephone, mail and the Internet,
from the public, members of Parliament, government All provinces and territories participate in hospital recip-
departments, stakeholder organizations and the media; rocal billing agreements, and all, with the exception of
Quebec, participate in hospital reciprocal billing agree-
• developing and maintaining formal and informal rela- ments. These agreements generally ensure that a
tionships with health officials in provincial and territorial patient’s health card will be accepted, in lieu of payment,
governments for information sharing; when the patient receives insured hospital or physician
services in another province or territory. The province or
• producing the Canada Health Act Annual Report on
territory providing the service will then directly bill the
the administration and operation of the CHA;
patient’s home province. The intent of these agreements
• conducting issue analysis and policy research to provide is to ensure that Canadian residents do not have to pay
strategic advice; directly for medically necessary hospital and physician
services when they travel within Canada.
• collaborating with provincial and territorial health de-
partment representatives through the Interprovincial Of note, these agreements are interprovincial, not federal,
Health Insurance Agreements Coordinating Committee and while they facilitate the portability criterion they are
(see below); not a requirement of the CHA.
• working in partnership with the provinces and territories IHIACC’s Rate Review Working Group is responsible for
to encourage compliance with the CHA; determining reciprocal billing rates to ensure that the host
province or territory that is providing the health service is
•
asking provincial and territorial health ministries to compensated by the home province at a reasonable rate.
investigate and provide information and clarification
when possible compliance issues arise, and, when Issues related to registration and eligibility requirements
necessary, recommending corrective action to them, are addressed through IHIACC’s Eligibility and Portability
in order to ensure the criteria and conditions of the Act Working Group which is responsible for reviewing eligi-
are upheld; bility issues and identifying potential inter-jurisdictional
gaps in health coverage.

During the reporting period, IHIACC added abortion COMPLIANCE ISSUES

services to reciprocal billing. This means that Canadian
residents who receive these services in hospital while For the most part, provincial and territorial health care
away from their home province or territory are no longer insurance plans meet the criteria and conditions of the
required to pay out-of-pocket and then seek reimburse- Canada Health Act. However, on the basis of their health
ment from their home province or territory. ministry’s report to Health Canada, a deduction in the
amount of $204,145 was taken from the March 2016
Canada Health Transfer payments to British Columbia
in respect of extra-billing and user charges for insured
Compliance health services at private clinics in fiscal year 2013-2014.
Health Canada’s approach to resolving possible compli- On March 31, 2016, the Government of Canada gave no-
ance issues emphasizes transparency, consultation and tice that it would appear as a party in the Cambie Surgeries
dialogue with provincial and territorial health ministry Corporation et al. v. Medical Services Commission et al.
officials. In most instances, issues are successfully litigation, before the British Columbia Supreme Court,
resolved through consultation and discussion based on pursuant to British Columbia’s Constitutional Question
a thorough examination of the facts. Act. The plaintiffs in the litigation are seeking to invalidate
provisions of British Columbia’s Medicare Protection Act
The Canada Health Act Division monitors the operations that prohibit user charges, extra-billing and private insur-
of provincial and territorial health care insurance plans ance for health services covered under British Columbia’s
in order to provide advice to the Minister on possible provincial health care insurance plan, on the basis that
non-compliance with the Canada Health Act. Sources these provisions violate sections 7 and 15 of the Canadian
for this information include: provincial and territorial Charter of Rights and Freedoms. Canada is making argu-
government officials and publications; media reports; ments in support of the constitutionality of provisions of
and correspondence received from the public and non- the Medicare Protection Act, which reflect the principles
governmental organizations. of the CHA.
Staff in the Compliance and Interpretation Unit of the Health Canada continues to monitor provincial and
Canada Health Act Division assess issues of concern and territorial compliance with the CHA. The following key
complaints on a case-by-case basis. The assessment developments occurred since the 2014-2015 Canada
process involves compiling all facts and information re- Health Act Annual Report was published:
lated to the issue and taking appropriate action. Verifying
the facts with provincial and territorial health officials Under the CHA, the definition of “hospital services”
may reveal issues that are not directly related to the specifies that standard or public ward level accommoda-
CHA, while others may pertain to the CHA but are a tion is an insured service. Charges for preferred accom-
result of misunderstanding or miscommunication, such modation are permissible under the CHA only where such
as eligibility for health insurance coverage and portability accommodation is not medically required, and is provided
of health services within and outside Canada, and are at the patient’s request. If ward level accommodation is
resolved quickly with provincial or territorial assistance. not available or cannot be offered, patients must be
provided private or semi-private accommodation at no
In instances where a CHA issue has been identified and charge. In January 2014, Health Canada learned that two
remains after initial enquiries, Division officials ask the hospitals are being built in Quebec that will have only
jurisdiction in question to investigate the matter and report semi-private and private rooms, and that the Quebec
back. Division staff discuss the issue and its possible res- health ministry considered permitting these hospitals to
olution with provincial or territorial officials. Only if the charge fees for all stays. Health Canada reviewed the
issue is not resolved to the satisfaction of the Division applicable provincial and territorial legislation and poli-
after following the aforementioned steps, is it brought to cies and found similar practices in Ontario and British
the attention of the Federal Minister of Health. Columbia. In July 2014, Health Canada informed the
health ministries of British Columbia, Ontario and Quebec
that such charges are contrary to the CHA. British Columbia
has since corrected the problem, while Ontario and
Quebec are still examining the issue.
16
During 2015-2016, Health Canada continued to consult In response to allegations of illegal patient charges in
with Alberta Health about private primary health care February 2016, by the Ontario Health Coalition, Health
clinics that charge patients annual enrollment and mem- Canada asked the Ontario Ministry of Health and Long-
bership fees. If the receipt of insured services is condi- Term Care (MOHLTC) for its assessment of the issue. In
tional upon the payment of fees, it would pose concerns June 2016, the MOHLTC replied, noting the Coalition’s
under the accessibility criterion of the CHA. Typically, allegations relied mainly on undated third-hand informa-
the fees cover a basket of uninsured services but also tion and provided few specific details of these charges,
promise quick access to and unrushed appointments which made investigating them difficult. The MOHLTC
with family physicians. In November 2013, Alberta prepared an assessment of the issues raised by the
Health informed Health Canada that it had completed an Coalition and informed Health Canada that no evidence
audit of an Edmonton clinic, which resulted in the clinic of illegal charges was found. The MOHLTC also noted
better communicating with patients about charges for that it has published information bulletins to physicians,
uninsured services. Alberta Health conducted similar hospitals and licensed independent health facilities to
audits at two other clinics and shared the results of all remind them of the prohibitions on extra-billing and user
three audits with Health Canada in January 2015. charges, as well as queue-jumping, under the Ontario
Throughout the subsequent reporting period of 2015- Commitment to the Future of Medicare Act and the
2016, there was a significant exchange of correspon- Independent Health Facilities Act. Health Canada was
dence between Alberta Health and Health Canada satisfied with this explanation and no further compliance
concerning the cessation of charges for insured services action was initiated.
and processes that were in place to reimburse patients
who had been inappropriately charged. In June 2016, In July 2015, Health Canada wrote to the Quebec Ministry
Health Canada was informed that new audits were to be of Health concerning Bill 20, which proposed to allow
conducted of the three clinics, as well as a fourth. Health patient charges (accessory fees) by physicians, when
Canada will continue to monitor this issue. they provide certain publicly insured health services in
their offices or private clinics. In May 2016, the Quebec
MRI and CT services are considered to be insured health Auditor-General released evidence of the magnitude of
services when they are medically necessary for the these charges in 2014-2015 and a group of Quebeckers
purpose of maintaining health, preventing disease or announced a lawsuit that sought to compel the Federal
diagnosing or treating an injury, illness or disability, Minister of Health to take deductions in respect of these
whether the scan is provided in a hospital or a clinic. In accessory charges. The Federal Minister of Health com-
February 2016, Saskatchewan passed the MRI Facilities municated her concerns over accessory fees to the
Licensing Act, which allows publicly insured residents to Quebec Health Minister in early September 2016 and
gain faster access to an MRI by paying for this insured on September 28, 2016, the Quebec Health Minister
service at a clinic, providing the clinic also provides a introduced draft regulations under Quebec’s health leg-
scan of comparable complexity to a resident waiting in islation, with the intent to eliminate these charges by
the public queue. Allowing access to care to be based January 2017. The lawsuit was subsequently withdrawn
on ability or willingness to pay rather than relative medi- and Health Canada’s consultation with Quebec on
cal need is a concern vis a vis the accessibility criterion charges levied before that date is ongoing.
of the Act as well as the prohibitions against extra-billing
and user charges. In November 2016, the Federal Minister Abortion services are insured in all provinces and territo-
wrote to her Saskatchewan counterpart expressing the ries; however, access to these insured services varies
federal government’s concerns about legislation which within and between jurisdictions across the country. In
authorizes individuals prepared to pay extra to receive Prince Edward Island and New Brunswick, the services
faster access to a medically necessary service. While are only covered if performed in a hospital; procedures
Saskatchewan is the only province that expressly encour- provided in the private clinic in Fredericton or other private
ages this practice through legislation, there is some clinics are not covered. Prince Edward Island lacks abor-
evidence of residents paying out of pocket to secure tion services on the island and residents must travel
faster access to diagnostic services in other provinces. off the island to access them, although the province
This issue will be the subject of dialogue with provinces announced on March 31, 2016, that it plans to introduce
and territories over the coming year. the service within the province. Because neither province
covers private clinic abortions under their respective

provincial health care insurance plans, accessibility and extra-billing and user charges, had taken appropriate
comprehensiveness concerns under the CHA remain. steps to eliminate them. Accordingly, by June 1987, a total
of $244,732,000 in deductions was refunded to New
During 2015-2016, Health Canada continued to monitor Brunswick ($6,886,000), Quebec ($14,032,000), Ontario
the following ongoing compliance and interpretation ($106,656,000), Manitoba ($1,270,000), Saskatchewan
issues: ($2,107,000), Alberta ($29,032,000) and British Columbia
($84,749,000).
Health Canada remains concerned about patient pay-
ments for drugs administered in hospital out-patient Following the CHA’s initial three-year transition period,
clinics and their appropriateness under the CHA, since under which refunds to provinces and territories for
drugs and biological products administered in hospitals deductions were possible, penalties under the CHA did
that are medically necessary for the purpose of maintain- not reoccur until fiscal year 1994-1995. Please refer to
ing health, preventing disease or diagnosing or treating the table at the end of this section for a summary of
an injury, illness or disability are insured health services deductions and refunds that have been made to provin-
under the CHA. cial or territorial transfer payments since 1994-1995.
Physician services received by Quebec residents when In the early 1990s, as a result of a dispute between the
out-of-province are not reimbursed at host province rates, British Columbia Medical Association and the British
which is a requirement of the portability criterion of the Columbia government over compensation, several doctors
CHA. Canadians from provinces other than Quebec also opted out of the provincial health care insurance plan
report difficulties having their provincial or territorial and began billing their patients directly. Some of these
health insurance cards honoured while out-of-province, doctors billed their patients at a rate greater than the
particularly by walk-in clinics, which runs counter to the amount the patients could recover from the provincial
spirit of the CHA. For all jurisdictions, except Prince health care insurance plan. This higher amount constituted
Edward Island and the three territories, the per diem extra-billing under the CHA. Deductions began in May
rates for out-of-country hospital services appear lower 1994, relating to fiscal year 1992-1993, and continued until
than home province or territory rates, which is contrary extra-billing by physicians was banned when changes to
to the requirement of the portability criterion of the CHA. 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
HISTORY OF DEDUCTIONS AND for extra-billing that occurred in the province between
REFUNDS UNDER THE CANADA 1992-1993 and 1995-1996. These deductions were non-
refundable, as were all subsequent deductions.
HEALTH ACT
In January 1995, Federal Minister of Health, Diane Marleau,
The Canada Health Act, which came into force April 1,
expressed concerns to her provincial and territorial
1984, reaffirmed the national commitment to the orig-
colleagues about the development of two-tiered health
inal principles of the Canadian health care system, as
care and the emergence of private clinics charging facility
embodied in the previous legislation, the Medical Care
fees for medically necessary services. As part of her com-
Act and the Hospital Insurance and Diagnostic Services
munication with the provinces and territories, Minister
Act. By putting into place mandatory dollar-for-dollar
Marleau announced that the provinces and territories
penalties for extra-billing and user charges, the federal
would be given more than nine months to eliminate
government took steps to eliminate the proliferation
these user charges, but that any province that did not,
of direct charges for hospital and physician services,
would face financial penalties under the CHA. Accord-
judged to be restricting the access of many Canadians
ingly, beginning in November 1995, deductions were
to health care services due to financial considerations.
applied to the cash contributions to Alberta, Manitoba,
During the period 1984 to 1987, subsection 20(5) of Nova Scotia, and Newfoundland and Labrador for non-
the CHA provided for deductions in respect of these compliance with the Federal Policy on Private Clinics.
charges to be refunded to the province if the charges
From November 1995 to June 1996, total deductions of
were eliminated before April 1, 1987. By March 31,
$3,585,000 were made to Alberta’s cash contribution in
1987, it was determined that all provinces, which had
respect of facility fees charged at clinics providing surgical,
18
ophthalmological and abortion services. On October 1, In 2004, British Columbia did not report to Health Canada
1996, Alberta prohibited private surgical clinics from the amounts of extra-billing and user charges actually
charging patients a facility fee for medically necessary charged during fiscal year 2001-2002, in accordance
services for which the physician fee was billed to the with the requirements of the Extra-billing and User
provincial health care insurance plan. Charges Information Regulations. As a result of reports
that British Columbia was investigating cases of user
Similarly, due to facility fees allowed at an abortion clinic, charges, a $126,775 deduction was taken from British
a total of $280,430 was deducted from Newfoundland Columbia’s March 2004 CHST payment, based on the
and Labrador’s cash contribution before these fees were amount the Minister estimated to have been charged
eliminated, effective January 1, 1998. during fiscal year 2001-2002.
From November 1995 to December 1998, deductions Since 2005, $1,457,290 in cash transfer deductions have
from Manitoba’s cash contribution amounted to been taken from British Columbia’s CHT payments in
$2,055,000, ending with the confirmed elimination of light of patient charges reported by the province to
user charges at surgical and ophthalmology clinics, Health Canada. The deduction taken in 2012-2013 in
effective January 1, 1999. However, during fiscal year respect of fiscal year 2010-2011 was estimated by the
2001-2002, a monthly deduction (from October 2001 to Federal Minister of Health and represents the aggregate
March 2002 inclusive) in the amount of $50,033 was of the amounts reported to Health Canada by British
levied against Manitoba’s Canada Health and Social Columbia and those reported publicly as the result of an
Transfer (CHST) cash contribution on the basis of a audit performed by the Medical Services Commission
financial statement provided by the province showing of British Columbia. This methodology was used in sub-
that actual amounts charged with respect to user sequent years. Deductions for each year are detailed in
charges for insured services in fiscal years 1997-1998 a table following this passage.
and 1998-1999 were greater than the deductions levied
on the basis of estimates. This brought total deductions A deduction of $1,100 was taken from the March 2005
levied against Manitoba to $2,355,201. CHT payment to Newfoundland and Labrador as a result
of patient charges for a magnetic resonance imaging
With the closure of a private clinic in Halifax effective scan in a hospital which occurred during 2002-2003. The
November 27, 2003, Nova Scotia was deemed to be in March 2007 CHT payment to Nova Scotia was reduced
compliance with the Federal Policy on Private Clinics. by $9,460 in respect of extra-billing during fiscal year
Before it closed, total deductions of $372,135 were 2004-2005.
made to Nova Scotia’s CHST cash contribution for its
failure to cover facility charges to patients while paying From March 2011 to March 2013, deductions totalling
the physician fee. A final deduction of $5,463 was taken $102,249 were taken from CHT payments to Newfoundland
from the March 2005 Canada Health Transfer (CHT) pay- and Labrador for extra-billing and user charges, based on
ment to Nova Scotia as a reconciliation of deductions charges reported by the province to Health Canada.
that had already been taken for 2002-2003. A one-time These charges resulted from services provided by an
positive adjustment in the amount of $8,121 was made opted-out dental surgeon who has since left the province
to Nova Scotia’s March 2006 CHT payment to reconcile and Health Canada considers this matter resolved.
amounts actually charged in respect of extra-billing and
user charges with the penalties that had already been Since the passage of the CHA, from April 1984 to March
levied based on provincial estimates reported for fiscal 2016, deductions totaling $10,316,592 have been taken
2003-2004. from transfer payments in respect of the extra-billing
and user charges provisions of the CHA. This amount
In January 2003, British Columbia provided a financial excludes deductions totaling $244,732,000 that were
statement in accordance with the Canada Health Act made between 1984 and 1987 and subsequently refunded
Extra-billing and User Charges Information Regulations, to the provinces when extra-billing and user charges
indicating aggregate amounts actually charged with were eliminated.
respect to extra-billing and user charges during fiscal
year 2000-2001, totaling $4,610. Accordingly, a deduc-
tion of $4,610 was made to the March 2003 CHST cash
contribution.

DEDUCTIONS AND REFUNDS TO CHST/CHT CASH CONTRIBUTIONS IN ACCORDANCE

Province/
Territory 1994/1995 1995/1996 1996/1997 1997/1998 1998/1999 1999/2000 2000/2001 2001/2002 2002/2003 2003/2004 2004/2005
NL 0 46,000 96,000 128,000 53,000 (42,570) 0 0 0 0 1,100
PEI 0 0 0 0 0 0 0 0 0 0 0
NS 0 32,000 72,000 57,000 38,950 61,110 57,804 35,100 11,052 7,119 5,463
NB 0 0 0 0 0 0 0 0 0 0 0
QC 0 0 0 0 0 0 0 0 0 0 0
ON 0 0 0 0 0 0 0 0 0 0 0
MB 0 269,000 588,000 586,000 612,000 0 0 300,201 0 0 0
SK 0 0 0 0 0 0 0 0 0 0 0
AB 0 2,319,000 1,266,000 0 0 0 0 0 0 0 0
BC 1,982,000 43,000 0 0 0 0 0 0 4,610 126,775 72,464
YK 0 0 0 0 0 0 0 0 0 0 0
NWT 0 0 0 0 0 0 0 0 0 0 0
NU 0 0 0 0 0 0 0 0 0 0 0
TOTAL 1,982,000 2,709,000 2,022,000 771,000 703,950 18,540 57,804 335,301 15,662 133,894 79,027
Understanding This Chart

• To date, most deductions have been made on the basis of statements of actual extra-billing and user charges, meaning they are
made two years after the extra-billing and user charges occurred.
• In instances where provinces and territories estimate anticipated amounts of extra-billing and user charges for the upcoming year,
a deduction is taken in respect of those charges in the fiscal year for which they are estimated.
20
WITH THE CANADA HEALTH ACT SINCE 1994–1995 (IN DOLLARS)
2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 Total
0 0 0 0 0 3,577 58,679 50,758 (10,765) 0 0 383,779
0 0 0 0 0 0 0 0 0 0 0 0
(8,121) 9,460 0 0 0 0 0 0 0 0 0 378,937
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 2,355,201
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 3,585,000
29,019 114,850 42,113 66,195 73,925 75,136 33,219 280,019 224,568 241,637 204,145 3,613,675
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
20,898 124,310 42,113 66,195 73,925 78,713 91.898 330,777 213,803 241,637 204,145 10,316,592
• In addition to forming the basis for most deductions under the Act, the statements of actual extra-billing and user charges provide
an opportunity to reconcile any estimated charges with those that actually occurred. These reconciliations form the basis for further
deductions or refunds to provincial and territorial cash transfers.
• Numbers in parentheses represent refunds to the province or territory.

CHAPTER 3
PROVINCIAL AND TERRITORIAL HEALTH

The following chapter presents the 13 provincial The process for the Canada Health Act Annual Report
and territorial health care insurance plans that 2015-2016 was launched late spring 2016 with bilateral
teleconferences. An updated User’s Guide was also
make up the Canadian publicly funded health
sent to the provinces and territories at that time.
insurance system. The purpose of this chapter is
to demonstrate clearly and consistently the
extent to which provincial and territorial plans HEALTH CARE INSURANCE
fulfilled the requirements of the Canada Health PLAN DESCRIPTIONS
Act program criteria and conditions in 2015-2016.
For the following chapter, provincial and territorial offi-
cials were asked to provide a narrative description of
their health care insurance plan. The descriptions follow
Officials in the provincial, territorial and federal govern- the program criteria areas of the Canada Health Act in
ments have collaborated to produce the detailed plan order to illustrate how the plans satisfy these criteria. This
overviews contained in Chapter 3. The information that narrative format also allows each jurisdiction to indicate
Health Canada requested from the provincial and territo- how it met the Canada Health Act requirement for the
rial departments of health for the report consists of two recognition of federal contributions that support insured
components: and extended health care services.
• a narrative description of the provincial or territorial

health care insurance plan relating to the criteria and PROVINCIAL AND TERRITORIAL
conditions of the Act, which can be found following
this introduction; and HEALTH CARE INSURANCE
PLAN STATISTICS
• statistical information related to insured health services.
Over time, the section of the annual report containing
The narrative component is used to help with the moni- the statistical information submitted from the provinces
toring and compliance of provincial and territorial health and territories has been simplified and streamlined
care insurance plans with respect to the requirements based on feedback received from provincial and territorial
of the Act, while statistics help to identify current and officials, and based on reviews of data quality and avail-
future trends in the Canadian health care system. While all ability. The supplemental statistical information tables
provinces and territories have submitted detailed descrip- can be found at the end of each provincial or territorial
tive information on their health care insurance plans, narrative, except for Quebec.
Quebec chose not to submit supplemental statistical infor-
mation which is contained in the tables in this year’s report. The purpose of the statistical tables is to place the ad-
ministration and operation of the Canada Health Act in
To help provinces and territories prepare their submis- context and to provide a national perspective on trends
sions to the Annual Report, Health Canada provided them in the delivery and funding of insured health services in
with the document; Canada Health Act Annual Report Canada that are within the scope of the Act.
2015-2016: A Guide for Updating Submissions (User’s
Guide). The User’s Guide is designed to help provinces The statistical tables contain resource and cost data for
and territories meet Health Canada’s reporting require- insured hospital, physician and surgical-dental services
ments. Annual revisions to the guide are based on by province and territory for five consecutive years end-
Health Canada’s analysis of health plan descriptions ing on March 31, 2016. All information was provided by
from previous annual reports and its assessment of provincial and territorial officials.
emerging issues relating to insured health services.
22
CHAPTER 3
CARE INSURANCE PLANS IN 2015-2016

Although efforts are made to capture data on a consistent Insured Physician Services Provided Outside Canada:
basis, differences exist in the reporting on health care This represents residents’ medical costs incurred while
programs and services between provincial and territorial travelling outside of Canada that are paid by their home
governments. Therefore, comparisons between jurisdic- province or territory.
tions are not made. Provincial and territorial governments
are responsible for the quality and completeness of the Insured Surgical-Dental Services within Own Prov-
data they provide. ince or Territory: The information in this subsection
describes insured surgical-dental services provided in
each province or territory.
ORGANIZATION OF
THE INFORMATION
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 pro-
vision 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 pro-
vision 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.

CHAPTER 3 | NEWFOUNDLAND AND LABRADOR
NE W F OU N D L AN D A N D L A B R A DO R
The Department of Health and Community With an annual budget of approximately $3 billion, the
Services (the Department) is responsible for set- Department accounts for approximately 40 per cent of
Newfoundland and Labrador’s total provincial budget.
ting the overall strategic directions and priorities
Budget 2015-2016 included investments for new and
for the health and community services system modern health care facilities and equipment; increased
throughout Newfoundland and Labrador. capacity for long-term care and community support ser-
vices; enhanced programming for mental health and
The Department works with stakeholders to de- addictions issues; and a renewed focus on primary
velop and enhance policies, legislation, provincial health care.
standards and strategies to support individuals,
In Newfoundland and Labrador, health services are pro-
families and communities to achieve optimal vided to over 520,000 residents by approximately 20,000
health and well-being. The Department provides health care providers, support staff and administrators.
a lead role in policy, planning, program develop-
ment, and support to the four regional health
authorities (RHAs). The Department also works
1.0 PUBLIC ADMINISTRATION
with stakeholders to ensure high quality, cost 1.1 Health Care Insurance Plan and Public Authority
effective and timely health services are available Health care insurance plans managed by the Department
include the Hospital Insurance Plan and the Medical
for all Newfoundlanders and Labradorians.
Care Plan (MCP). Both plans are non-profit and publicly
The Department provides leadership, coordina- administered.
tion, monitoring and support to the RHAs who As of March 31, 2016, the Hospital Insurance Agreement
deliver the majority of publicly funded health Act was the legislation that enabled the Hospital
services in the province, as well as other entities Insurance Plan. The Act gave the Minister of Health and
Community Services the authority to make regulations
who deliver programs and services. This ensures
for providing insured services on uniform terms and
quality, efficiency and effectiveness in areas such conditions to residents of the province and which comply
as the administration of health care facilities; ac- with the Canada Health Act and its Regulations.
cess and clinical efficiency; programs for seniors,
As of March 31, 2016, the Medical Care Insurance Act,
persons with disabilities and persons with mental
1999 required the Minister to administer a plan of medi-
health and addictions issues as well as long-term cal care insurance for residents of the province. It provid-
care and community support services; health ed for the development of regulations to ensure that the
professional education and training programs; provisions of the statute meet the requirements of the
the control, possession, handling, keeping and Canada Health Act as it relates to administering the MCP.
sale of food and drugs; the preservation and pro- The MCP facilitates the delivery of comprehensive
motion of health; the prevention and control of medical care to all residents of the province by
disease; and public health and the enforcement implementing policies, procedures and systems that
of public health standards. permit appropriate compensation to providers for ren-
dering insured professional services. The MCP operates
in accordance with the provisions of the Medical Care
Insurance Act, 1999 and Regulations, and in compliance
with the Canada Health Act.
24
There were no substantive legislative amendments to out by personnel from the Department under the authority
the Medical Care Insurance Act, 1999 or the Hospital of the Medical Care Insurance Act, 1999. Physician records
Insurance Agreement Act in 2015–2016. (Note: The and professional medical corporation records are re-
Medical Care and Hospital Insurance Act came into viewed to ensure that the records supported the services
force on October 1, 2016, replacing both the Medical billed and that the services are insured under the MCP.
Care Insurance Act, 1999 and the Hospital Insurance
Agreement Act. As the implementation of this new Beneficiary audits are performed by personnel from the
legislation falls outside of the reporting period of this Department under the Medical Care Insurance Act, 1999.
document, references to the new legislation will be Individual providers are randomly selected on a bi-weekly
included in next year’s annual report.) basis for audit.
1.2 Reporting Relationship

The Department is mandated with administering the 2.0 COMPREHENSIVENESS
Hospital Insurance and Medical Care Plans. The
2.1 Insured Hospital Services
Department reports on these plans through the regular
As of March 31, 2016, the Hospital Insurance Agreement
legislative processes, e.g., Public Accounts and the
Act and the Hospital Insurance Regulations, made
Social Services Committee of the House of Assembly, as
thereunder, provided for insured hospital services in
well as through other legislation.
Newfoundland and Labrador. All the services listed
The Government of Newfoundland and Labrador has a under the Canada Health Act are insured services in
provincial planning and reporting requirement for all Newfoundland and Labrador.
government departments, including the Department of
Insured hospital services are provided for in-patients
Health and Community Services. Under the Transparency
and out-patients in 15 hospitals, 22 community health
and Accountability Act, the Department of Health and
centres and 14 community clinics as well as numerous
Community Services and the 12 entities that report to the
health and community services clinics throughout the
Minister, including RHAs, produce a strategic plan once
province. Insured services include: accommodations
every three years and report annually on performance.
and meals at the standard ward level; nursing services;
Plans and reports are tabled in the House of Assembly
laboratory, radiology and other diagnostic procedures;
and posted on the Department’s website. http://www.
drugs, biologicals and related preparations; medical
assembly.nl.ca.
and surgical supplies; operating room, case room and
The 2015–2016 Department of Health and Community anaesthetic facilities; rehabilitative services (e.g.,
Services Annual Report was tabled in the House of physiotherapy, occupational therapy, speech language
Assembly on September 30, 2016. pathology and audiology); out-patient and emergency
visits; and day surgery.
1.3 Audit of Accounts
Each year, the province’s Auditor General independently The coverage policy for insured hospital services is linked
examines provincial public accounts. MCP expenditures to the coverage policy for insured medical services. The
are considered a part of the public accounts. While Department manages the process of adding or de-listing
respecting privacy and personal information, the Auditor a hospital service from the list of insured services based
General has full and unrestricted access to code-based on direction from the Lieutenant-Governor in Council.
MCP records. There were no services added or de-listed in 2015–2016.
The four RHAs are subject to financial statement audits, 2.2 Insured Physician Services
reviews, and compliance audits. Financial statement As of March 31, 2016, the enabling legislation for insured
audits are performed by independent auditing firms that physician services was the Medical Care Insurance Act,
are selected by the health authorities. Review engage- 1999 and the Regulations made thereunder, which
ments, compliance audits and physician audits are carried included the:

• Medical Care Insurance Insured Services Regulations; Act or the Regulations relating to the provision of in-
sured services to beneficiaries or the payment to be
• Medical Care Insurance Beneficiaries and Inquiries made for the services and the professional medical cor-
Regulations; and poration and the physician providing the insured ser-
vices shall comply with subsection (1).
• Physicians and Fee Regulations.
As of March 31, 2016 there were no physicians who had
In 2015–2016 (as of March 31, 2016) there were 1,212
opted out of the MCP.
physicians (salaried and fee-for-service) active in practice
in the province. The Lieutenant-Governor in Council approval is required
to add to or to de-insure a physician service from the list
For purposes of the Act, the following services are
of insured services. This process is managed by the
covered:
Department in consultation with various stakeholders.
• all services properly and adequately provided by physi-
2.3 Insured Surgical-Dental Services
cians to beneficiaries suffering from an illness requiring
The provincial Surgical-Dental Program is a component of
medical treatment or advice;
the MCP. Surgical-dental treatments provided to a benefi-
• group immunizations or inoculations carried out by phy- ciary and carried out in a hospital by a licensed oral surgeon
sicians at the request of the appropriate authority; and or dentist are covered by the MCP if the treatment is
specified in the Surgical-Dental Services Schedule.
• diagnostic and therapeutic x-ray and laboratory ser-
vices in facilities approved by the appropriate authority Dentists may opt out of the MCP. These dentists must
that are not provided under the Hospital Insurance advise the patient of their opted-out status, state the fees
Agreement Act and Regulations made under the Act. expected, and provide the patient with a written record of
services and fees charged. As of March 31, 2016, there
Physicians can choose not to participate in the health care were no opted-out dentists. There was no extra-billing in
insurance plan as outlined in section 12(1) of the Medical 2015–16.
Care Insurance Act, 1999, namely:
Because the Surgical-Dental Program is a component of
12(1) Where a physician providing insured services is not the MCP, management of the program is linked to the
a participating physician, and the physician provides an MCP process regarding changes to the list of insured
insured service to a beneficiary, the physician is not services.
subject to this Act or the Regulations relating to the provi-
sion of insured services to beneficiaries or the payment Addition of a surgical-dental service to the list of insured
to be made for the services except that he or she shall: services must be approved by the Minister.
a)
before providing the insured service, if he or she 2.4 Uninsured Hospital, Physician and
wishes to reserve the right to charge the beneficiary Surgical-Dental Services
for the service an amount in excess of that payable by Hospital services not covered by the MCP include: pre-
the Minister under this Act, inform the beneficiary that ferred accommodation at the patient’s request; cosmetic
he or she is not a participating physician and that the surgery and other services deemed to be medically
physician may so charge the beneficiary; and unnecessary; ambulance or other patient transportation
before admission or upon discharge; private duty nursing
b)
provide the beneficiary to whom the physician has arranged by the patient; non-medically required x-rays or
provided the insured service with the information other services for employment or insurance purposes;
required by the Minister to enable payment to be made drugs (except anti-rejection and AZT drugs) and appli-
under this Act to the beneficiary in respect of the ances issued for use after discharge from hospital;
insured service. bedside telephones, radios or television sets for personal,
non-teaching use; fibreglass splints; services covered
(2) Where a physician who is not a participating physi- by the Workplace Health, Safety and Compensation
cian provides insured services through a professional Commission or by other federal or provincial legislation;
medical corporation, the professional medical corpora- and services relating to therapeutic abortions performed
tion is not, in relation to those services, subject to this
26
in non-accredited facilities or facilities not approved by • the fees of a dentist, oral surgeon or general practitioner
the College of Physicians and Surgeons of Newfoundland for routine dental extractions performed in hospital;
and Labrador.
• fluoride dental treatment for children under four years
The use of the hospital setting for any services deemed of age;
not insured by the MCP is also uninsured under the
Hospital Insurance Plan. For purposes of the Medical • excision of xanthelasma;
Care Insurance Act, 1999, the following is a list of non-
• circumcision of newborns;
insured physician services:
• hypnotherapy;
•
any advice given by a physician to a beneficiary by
telephone; • medical examination for drivers;
• the dispensing by a physician of medicines, drugs or • alcohol/drug treatment outside Canada;
medical appliances and the giving or writing of medical
prescriptions; • consultation required by hospital regulation;
• the preparation by a physician of records, reports or • therapeutic abortions performed in the province at a
certificates for, or on behalf of, or any communication facility not approved by the College of Physicians and
to, or relating to, a beneficiary; Surgeons of Newfoundland and Labrador;
• any services rendered by a physician to the spouse and • sex reassignment surgery, when not recommended by
children of the physician; the Clarke Institute of Psychiatry;
• any service to which a beneficiary is entitled under an • in vitro fertilization and OSST (ovarian stimulation and
Act of the Parliament of Canada, an Act of the Province sperm transfer);
of Newfoundland and Labrador, an Act of the legislature
• reversal of previous sterilization procedure;
of any province of Canada, or any law of a country or
part of a country; • surgical, diagnostic or therapeutic procedures provided
in facilities as of January 1998 other than those covered
• the time taken or expenses incurred in travelling to
under the Hospital Insurance Agreement Act or
consult a beneficiary;
approved by the appropriate authority under paragraph
•
ambulance service and other forms of patient 3(d) of the Medical Care Insurance Insured Services
transportation; Regulations; and
•
acupuncture and all procedures and services • other services not within the ambit of section 3 of the
related to acupuncture, excluding an initial assessment Medical Care Insurance Insured Services Regulations.
specifically related to diagnosing the illness proposed
The majority of diagnostic services (e.g., laboratory
to be treated by acupuncture;
services and x-ray) are performed within public facilities in
•
examinations not necessitated by illness or at the the province. Hospital policy concerning access ensures
request of a third party except as specified by the that third parties are not given priority access.
Department;
Medical goods and services that are implanted and
• plastic or other surgery for purely cosmetic purposes, associated with an insured service are provided
unless medically indicated; free of charge to the patient and are consistent with
national standards of practice. Patients retain the right to
• laser treatment of telangiectasia; financially upgrade standard medical goods or services.
Standards for medical goods are developed by the
• testimony in a court;
hospitals providing those services in consultation with
• visits to optometrists, general practitioners and ophthal- service providers.
mologists solely for determining whether new or re-
placement glasses or contact lenses are required;

The Medical Care Insurance Act, 1999 provided the valid immigration documents are also eligible, subject to
Lieutenant-Governor in Council with the authority to MCP approval. Dependents of a MCP beneficiary may
make regulations prescribing which services are or are also be eligible for coverage.
not insured services for the purpose of the Act.
4.0 PORTABILITY
3.0 UNIVERSALITY
4.1 Minimum Waiting Period
3.1 Eligibility Insured persons moving to Newfoundland and Labrador
There were 532,415 people registered with the MCP as from other provinces or territories are entitled to
of March 31, 2016. Residents of Newfoundland and coverage on the first day of the third month following
Labrador were eligible for coverage under the Medical the month of arrival.
Care Insurance Act, 1999 and the Hospital Insurance
Agreement Act. The Medical Care Insurance Act, 1999 Persons arriving from outside Canada to establish
defined a “resident” as a person lawfully entitled to be or residence are entitled to coverage on the day of
to remain in Canada, who makes his or her home and is arrival. The same applies to discharged members of the
ordinarily present in the province, but does not include Canadian Forces, and individuals released from federal
tourists, transients or visitors to the province. penitentiaries. For coverage to be effective, registration
is required under the MCP. Immediate coverage is
The Medical Care Insurance Beneficiaries and Inquiries provided to persons from outside Canada authorized to
Regulations identified those residents eligible to receive work in the province for one year or more and their
coverage under the plans. The MCP has established rules eligible dependents, and to international post-secondary
to ensure that the Regulations are applied consistently students attending a recognized Newfoundland and
and fairly in processing applications for coverage. The Labrador educational institution who have a valid study
MCP applies the standard that persons moving to permit entitling them to stay in Canada for more than
Newfoundland and Labrador from another province 365 days and their eligible dependents.
become eligible on the first day of the third month
following the month of their arrival. 4.2 Coverage During Temporary Absences in Canada
Newfoundland and Labrador is a party to the Interprovincial
Persons not eligible for coverage under the plans include: Agreement on Eligibility and Portability regarding matters
students and their dependents already covered by pertaining to portability of insured services in Canada.
another province or territory; dependents of residents if
covered by another province or territory; certified Sections 12 and 13 of the Hospital Insurance Regulations
refugees and refugee claimants and their dependents; define portability of hospital coverage during absences
foreign workers with employment authorizations and both within and outside Canada. The eligibility policy for
their dependents who do not meet the established insured hospital services is linked to the eligibility policy
criteria; foreign seasonal workers, tourists, transients, for insured physician services.
visitors and their dependents; Canadian Forces
Coverage is provided to residents during temporary ab-
personnel; inmates of federal prisons; and armed forces
sences within Canada. The Government of Newfoundland
personnel from other countries who are stationed in the
and Labrador has entered into formal agreements (e.g.,
province. If the status of these individuals changes, they
the Hospital Reciprocal Billing Agreement) with other
must meet the criteria for eligibility as noted above in
provinces and territories for the reciprocal billing of insured
order to become eligible.
hospital services. In-patient costs are paid at standard
3.2 Other Categories of Individuals rates approved by the host province or territory. In-patient,
Foreign workers, international students, foreign clergy and high-cost procedures and out-patient services are pay-
dependents of North Atlantic Treaty Organization (NATO) able based on national rates agreed to by provincial and
personnel are eligible for benefits. Returning Canadian territorial health plans through the Interprovincial Health
citizens and their dependents born out of country, Insurance Agreements Coordinating Committee.
returning permanent residents who hold valid documenta-
tion, holders of Minister’s permits, Convention Refugee,
Resettled Refugee or “Person in Need of Protection” with
28
Medical services incurred in all provinces (except Insured residents moving permanently to other parts of
Quebec) or territories, are paid through the Medical Canada are covered up to and including the last day of
Reciprocal Billing Agreement at host province or territory the second month following the month of departure.
rates. Claims for medical services received in Quebec are
submitted by the patient to the MCP for payment at host 4.3 Coverage During Temporary
province rates. Absences Outside Canada
The province provides coverage to residents during
In order to qualify for out-of-province coverage, a temporary absences outside Canada. Out-of-country
beneficiary must comply with the legislation and the insured hospital in-patient and out-patient services are
MCP rules regarding residency in Newfoundland and covered for emergencies, sudden illness, and elective
Labrador. A resident must reside in the province at least procedures at established rates listed below. Hospital
four consecutive months in each 12-month period to services are considered under the Plan when the insured
qualify as a beneficiary. Generally, the rules regarding services are provided by a recognized facility (licensed
medical and hospital care coverage during absences or approved by the appropriate authority within the
include the following: state or country in which the facility is located) outside
Canada. The maximum amount payable by the
•
Before leaving the province for extended periods government’s hospitalization plan for out-of-country
(more than 30 days), a resident is encouraged to con- in-patient hospital care is $350 per day, if the insured
tact the MCP to obtain an out-of-province coverage services are provided by a community or regional
certificate (a certificate); hospital. Where insured services are provided by a
tertiary care hospital (a highly specialized facility), the
•
Beneficiaries leaving for vacation purposes may
approved rate is $465 per day. The approved rate for
receive an initial out-of-province coverage certificate
out-patient services is $62 per visit and haemodialysis
of up to 12 months. Upon return, beneficiaries are
is $330 per treatment. The approved rates are paid in
required to reside in the province for a minimum four
Canadian funds.
consecutive months. Thereafter, certificates will only
be issued for up to eight months of coverage; Physician services are covered for emergencies or
sudden illness, and are also insured for elective ser-
•
Students leaving the province may receive a
vices not available in the province or within Canada.
certificate, renewable each year, provided they submit
Emergency physician services are paid at the same rate
proof of full-time enrolment in a recognized educational
as would be paid in Newfoundland and Labrador for the
institution located outside the province;
same service. If the elective services are not available
• Persons leaving the province for employment purposes in Newfoundland and Labrador, they are usually paid at
may receive a certificate for coverage up to 12 months. Ontario rates, or at rates that apply in the province
Verification of employment may be required; where they are available.
•
Persons must not establish residency in another Coverage is immediately discontinued when residents
province, territory or country while maintaining move permanently to other countries.
coverage under the MCP;
4.4 Prior Approval Requirement
• For out-of-province trips of 30 days or less, an out-of- Prior approval is not required for medically necessary
province coverage certificate is not required, but will insured services provided by accredited hospitals or
be issued upon request; and licensed physicians in the other provinces and
territories. However, physicians may seek advice on
• For out-of-province trips lasting more than 30 days, a coverage from the MCP so that patients may be made
certificate is recommended as proof of a resident’s aware of any financial implications.
ability to pay for services while outside the province.
Prior approval is mandatory in order to receive funding at
Failure to request out-of-province coverage or failure to host country rates if a resident of the province has to
abide by the residency rules may result in the seek specialized hospital care outside the country
resident having to pay for medical or hospital costs because the insured service is not available in Canada.
incurred outside the province. The referring physicians must contact the Department for

prior approval. If prior approval is granted, the provincial Since Newfoundland and Labrador’s strategy was
health care insurance plan will pay the costs of insured released (2012), we have seen a 41 per cent increase
services necessary for the patient’s care. Prior approval (from 1021 to 1440) in the number of hip and knee
is not granted for out-of-country treatment or elective replacement surgeries being completed, as Provincial
services if the service is available in the province or else- Government funding was provided to perform an
where within Canada. If an individual opts to receive the additional 60 joint replacement surgeries annually.
service outside Canada it will be covered at the provincial Additionally, with the implementation of inpatient
rate if available in Newfoundland and Labrador. If the ser- weekend physiotherapy services and standard patient
vices are not available in Newfoundland and Labrador, care pathways, the average length of stay was
they are usually paid at Ontario rates, or at rates that decreased post-operatively to less than 4 days, so that
apply in the province where they are available. the additional joint replacement patients were cared for
in the existing orthopaedic inpatient beds.
5.0 ACCESSIBILITY Through the actions of the Provincial Emergency

Department Wait Time Strategy, external reviews were
5.1 Access to Insured Health Services carried out at three additional emergency departments in
Access to insured health services in Newfoundland and the province. We are improving emergency departments
Labrador is provided on uniform terms and conditions. to ensure there are shorter wait times and patients are
There are no co-insurance charges for insured hospital assessed and treated in a timely manner. We have now
services and there is no extra-billing by physicians in the completed external reviews in all 13 Category A emer-
province. gency departments. Through these reviews, a variety of
initiatives were undertaken to improve wait times,
The Department works closely with post-secondary including Nurse First triage, alignment of staffing alloca-
educational institutions within the province to maintain an tions to meet peak patient demand; implementation of
appropriate supply of health professionals. The province fast track units to treat low acuity patients, and continued
also works with external organizations for health profes- use of the provincial HealthLine to carry out follow-up
sionals not trained in this province. Targeted recruitment contact with patients who left without being seen.
incentives are in place to attract health professionals.
Several programs have been established to provide Many, if not all, emergency departments in Canada expe-
targeted sign-on bonuses, bursaries, opportunities for rience overcrowding, which contributes to increases in
upgrading, and other incentives for a wide variety of the number of left without being seen patients (LWBS).
health occupations. To help alleviate overcrowding issues, the team at one of
the rural emergency departments (Carbonear General
Newfoundlanders and Labradorians continue to have Hospital, Eastern RHA, developed and implemented an
some of the best benchmark wait times in the country. innovative surge capacity tool (Surgecon) this year. The
Newfoundland and Labrador is ranked as the second best Surgecon tool is a site specific plan used to quantify
in Canada in the wait times for hip and knee replacement patient load in order to proactively predict and avoid over-
and cataract surgery. Furthermore, according to the crowding in the emergency department through a series
Canadian Institute for Health Information annual report of triggers and actions to divert the backlog of patients
Wait Times for Priority Procedures in Canada, and consequently, prevent overcrowding. As a result of
Newfoundland and Labrador was one of only two this innovative initiative, we are seeing reductions in the
provinces to achieve 9 out of 10 (90 per cent) benchmark time for physician initial assessment and the number of
results in the majority of benchmarked procedures. LWBSs, as well as a decrease in the number of Over-
Newfoundland and Labrador continues to be a national Capacity Protocol activations in this rural emergency
leader in wait time improvements. These improvements department.
are the result of actions implemented under three Through the actions of the Provincial Endoscopy Wait
provincial strategies: the Provincial Emergency Time Strategy, work has begun to implement an
Department Wait Time Strategy; the Provincial Hip and automated appointment reminder system for endosco-
Knee Joint Replacement Wait Time Strategy, and the py services provincially. Through our work in partnership
Provincial Endoscopy Wait Time Strategy. with Canadian Association of Gastroenterologists (CAG),
30
physicians and the four RHAs, the province is still the Any adjustments to the annual funding level, such as for
only province in Canada in which 100 per cent (12/12) of additional approved positions or program changes, were
endoscopy suites are enrolled in the CAG Quality funded based on the implementation date of such
Program and have continued to complete the Canadian increases and the cash flow requirements.
Global Rating Scale (GRS-CA) self-assessment bi-annually
since early in 2014. Additionally, the Department continued
its work with the Eastern RHA, in partnership with CAG, 6.0 RECOGNITION GIVEN TO
to continue offering the Skills Enhancement in Endoscopy FEDERAL TRANSFERS
(SEE) program in the province. As a result of this work,
Eastern RHA continues to be a designated training site Funding provided by the federal government through the
for the SEE program in Newfoundland and Labrador as Canada Health Transfer and the Canada Social Transfer
physician faculty members have achieved SEE Master has been recognized and reported by the Government of
Trainer Designation. Newfoundland and Labrador in the annual provincial
budget, through press releases, government websites
5.2 Physician Compensation and various other documents. For fiscal year 2015–2016,
As of March 31, 2016, the legislation governing payments these documents include the 2015–2016 Public Accounts
to physicians and dentists for insured services was the and Estimates 2015–2016. The Public Accounts and
Medical Care Insurance Act, 1999. Compensation agree- Estimates, tabled by the Government in the House of
ments are negotiated between the provincial government Assembly, are publicly available and are shared with
and the Newfoundland and Labrador Medical Association Health Canada for information purposes.
(NLMA), on behalf of all physicians. Representatives from
the RHAs play a role in this process. A Memorandum of
Agreement was reached with the NLMA in December
2010, which increased overall physician compensation by
approximately 26 per cent. The Agreement expired on
September 30, 2013 but remains in effect until such time
as a new agreement is negotiated. Physicians are paid via
fee-for-service, salary or alternate payment plan (APP)
with an increasing interest in APPs as a method of
remuneration by physicians.
5.3 Payments to Hospitals

The Department is responsible for funding RHAs for
ongoing operations and capital acquisitions. Funding for
insured services is provided to the RHAs as an annual
global budget. Payments were made in accordance with
the Hospital Insurance Agreement Act and the Regional
Health Authorities Act. As part of their accountability to
the government, the health authorities are required to
meet the Department’s annual reporting requirements,
which include audited financial statements and other
financial and statistical information. The global budgeting
process devolves the budget allocation authority,
responsibility, and accountability to all appointed boards
in the discharge of their mandates.
Throughout the fiscal year, the RHAs forwarded

additional funding requests to the Department for any
changes in program areas or increased workload volume.
These requests were reviewed and, when approved
by the Department, funded at the end of the fiscal year.

REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number as of March 31st (#) 527,714 530,521 532,177 533,156 532,415
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 51 51 51 51 51
Payments for insured health services ($) 1,088,392,487 1,097,535,388 1,100,291,277 1,131,546,830 1,164,174,814
PRIVATE FOR-PROFIT FACILITIES

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of private for-profit facilities 1 1 1 1 1
providing insured health services (#)
Payments to private for-profit facilities 697,375 845,280 916,696 914,135 899,538
for insured health services ($)
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS

IN ANOTHER PROVINCE OR TERRITORY
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total number of claims, in-patient (#) 1,648 1,844 1,574 1,773 1,607
Total payments, in-patient ($) 17,507,684 19,988,002 20,969,617 22,423,411 21,928,705
Total number of claims, out-patient (#) 23,482 27,681 22,429 26,671 23,105
Total payments, out-patients ($) 7,216,918 8,827,387 8,109,628 9,147,633 8,428,054
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total number of claims, in-patient (#) 126 108 127 141 150
Total payments, in-patient ($) 224,822 139,270 451,834 207,198 620,866
Total number of claims, out-patient (#) 475 410 445 570 561
Total payments, out-patients ($) 91,089 96,116 105,448 71,574 62,285
32
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of participating 1,115 1,155 1,183 1,199 1,212
physicians (#)1,2
Number of opted-out 0 0 0 0 0
physicians (#)
Number of non-participating 0 0 0 0 0
physicians (#)
Total payments for services not available not available not available not available not available
provided by physicians paid
through all payment methods ($)
Total payments for services 218,561,000 236,529,000 251,281,302 294,572,803 299,597,724
through fee-for-service ($)
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS

IN ANOTHER PROVINCE OR TERRITORY 3
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services (#) 154,000 114,000 114,000 106,000 114,000
Total payments ($) 6,627,000 6,762,000 6,954,000 6,836,000 6,910,000
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 237,000 231,000 266,000 223,000 236,000
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of participating dentists (#) 25 25 26 19 19
Number of services provided (#) 2,222 2,880 1,585 1,709 3,397
Total payments ($) 329,000 455,780 203,610 279,350 592,660
1 Excludes inactive physicians. Total salaried and fee-for-service.

2 Updated figure for 2014-2015.
3 Numbers are rounded to the nearest thousand.

CHAPTER 3 | PRINCE EDWARD ISLAND
PRI N CE E DWAR D IS L A N D
In Prince Edward Island (PEI) the Department of centres, manors and mental health facilities. Health
Health and Wellness is responsible for providing PEI is responsible for the hiring of physicians, while the
Public Service Commission of PEI hires nurse practi-
policy, strategic, and fiscal leadership for the
tioners, nurses and all other health related workers.
health care system.
An annual report is submitted by the Department to the
Minister responsible who tables it in the Legislative
The Health Services Act provides the regulatory and ad-
Assembly. The report provides information about the
ministrative frameworks for improvements to the health
operating principles of the Department and its legislative
care system in PEI by:
responsibilities, as well as an overview and description
• mandating the creation of a provincial health plan; of the operations of the departmental divisions and
statistical highlights for the year.
• establishing mechanisms to improve patient safety and
support quality improvement processes; and Health PEI prepares an annual business plan which
functions as a formal agreement between Health PEI
• creating a Crown corporation (Health PEI) to oversee and the Minister responsible, and documents accom-
the delivery of operational health care services. plishments to be achieved over the coming fiscal year.
Within this governance structure Health PEI has the 1.3 Audit of Accounts
responsibility to: The provincial Auditor General conducts annual audits of
• provide, or provide for the delivery of, health services; the public accounts of PEI. The public accounts of the
province include the financial activities, revenues and
• operate and manage health facilities; expenditures of the Department of Health and Wellness.
• manage the financial, human and other resources nec- The provincial Auditor General, through the Audit Act,
essary to provide health services and operate health has the discretion to conduct further audit reviews on a
facilities; and comprehensive or program specific basis.
• perform such other duties as the Minister may direct.

2.0 COMPREHENSIVENESS
1.0 PUBLIC ADMINISTRATION 2.1 Insured Hospital Services
Insured hospital services are provided under the Hospi-
1.1 Health Care Insurance Plan and Public Authority tal and Diagnostic Services Insurance Act (1988). The
The Hospital Services Insurance Plan, under the author- accompanying Regulations define the insured in-patient
ity of the Minister of Health and Wellness, is the vehicle and out-patient hospital services available at no charge
for delivering hospital care insurance in Prince Edward to a person who is eligible. Insured hospital services in-
Island (PEI). The enabling legislation is the Hospital and clude, but are not limited to: necessary nursing services;
Diagnostic Services Insurance Act (1988). The Medical laboratory, radiological and other diagnostic procedures;
Services Insurance Plan provides for insured physician accommodations and meals at a standard ward rate;
services under the authority of the Health Services formulary drugs, biologicals and related preparations
Payment Act (1988). Together, the plans insure services prescribed by an attending physician and administered
as defined under section 2 of the Canada Health Act. in hospital; operating room, case room and anaesthetic
The Department of Health and Wellness is responsible facilities; routine surgical supplies; and radiotherapy and
for providing policy, strategic and fiscal leadership for the physiotherapy services performed in hospital.
health care system, while Health PEI is responsible for The process to add a new hospital service to the list of
service delivery and the operation of hospitals, health insured services involves extensive consultation and
34
negotiation between the Department, Health PEI and key of anaesthetists and surgical assistants where necessary;
stakeholders. The process involves the development of obstetrical services, including pre-natal and post-natal care,
a business plan which, when approved by the Minister, newborn care or any complications of pregnancy such as
would be taken to Treasury Board for funding approval. miscarriage or caesarean section; certain oral surgery
Executive Council (Cabinet) has the final authority in procedures performed by an oral surgeon when it is med-
adding new services. ically required, with prior approval that they be performed
in a hospital; sterilization procedures, both female and
2.2 Insured Physician Services male; treatment of fractures and dislocations; and certain
The enabling legislation that provides for insured physi- insured specialist services, when properly referred by an
cian services is the Health Services Payment Act. attending physician.
Insured physician services are provided by medical prac- The process to add a physician service to the list of insured
titioners licensed by the College of Physicians and services involves negotiation between the Department,
Surgeons. The total number of practicing practitioners Health PEI and the Medical Society. The process involves
who billed the Medical Services Insurance Plan as of development of a business plan which, when approved
March 31, 2016 was 357. This includes all physicians by the Minister, would be taken to Treasury Board for
(complement, locums, visiting specialists, and other funding approval. Insured physician services may also
non-complement physicians). Prior to 2012–2013, Prince be added or deleted as part of the negotiation of a new
Edward Island (PEI) reported complement physicians only. Master Agreement with physicians (Section 5.2). Cabinet
has the final authority in adding new services.
Under section 10 of the Health Services Payment Act, a
physician or practitioner who is not a participant in the 2.3 Insured Surgical-Dental Services
Medical Services Insurance Plan is not eligible to bill the Dental services are not insured under the Medical Services
Plan for services rendered. When a non-participating Insurance Plan. Only oral maxillofacial surgeons are paid
physician provides a medically required service, section through the Plan. There are currently two surgeons in
10(2) requires that physicians advise patients that they that category. Surgical-dental procedures included as
are non-participating physicians or practitioners and basic health services in the Tariff of Fees are covered
provide the patient with sufficient information to enable only when the patient’s medical condition requires that
recovery of the cost of services from the Minister of they be done in hospital or in an office with prior approval,
Health and Wellness. Under section 10.1 of the Health as confirmed by the attending physician.
Services Payment Act, a participating physician or
practitioner may determine, subject to and in accor- 2.4 Uninsured Hospital, Physician and
dance with the Regulations and in respect of a particular Surgical-Dental Services
patient or a particular basic health service, to collect
fees outside the Plan or selectively opt out of the Plan. Services not covered by the Hospital Services
Before the service is rendered, patients must be informed Insurance Plan include:
that they will be billed directly for the service. Where •
services that persons are eligible for under other
practitioners have made that determination, they are provincial or federal legislation;
required to inform the Minister thereof and the total
charge is made to the patient for the service rendered. • mileage or travel, unless approved by Health PEI;
As of March 31, 2016, no physicians had opted out of • telephone consultation except by internists, palliative
the Medical Services Insurance Plan. care physicians, paediatricians, out-of-province spe-
cialists, and orthopedic surgeons, provided the patient
Any basic health services rendered by physicians that are was not seen by that physician within three days of
medically required are covered by the Medical Services the telephone consult;
Insurance Plan. These include most physicians’ services
in the office, at the hospital or in the patient’s home; med- • examinations required in connection with employment,
ically necessary surgical services, including the services insurance, education, etc.;

•
group examinations, immunizations or inoculations, The process to de-insure services covered by the Medical
unless prior approval is received from Health PEI; Services Insurance Plan is done in collaboration with the
Medical Society, Health PEI and the Department. No ser-
• preparation of records, reports, certificates or com- vices were de-insured during the 2015–2016 fiscal year.
munications, except a certificate of committal to a
psychiatric, drug or alcoholism facility; All PEI residents have equal access to services. Third
parties such as private insurers or the Workers’
• testimony in court; Compensation Board of PEI do not receive priority
access to services through additional payment.
• travel clinic and expenses;
PEI has no formal process to monitor compliance; how-
• surgery for cosmetic purposes unless medically required;
ever, feedback from physicians, hospital administrators,
• dental services other than those procedures included medical professionals and staff allows the Department
as basic health services; and Health PEI to monitor usage and service concerns.
•
dressings, drugs, vaccines, biologicals and related
materials; 3.0 UNIVERSALITY
• eyeglasses and special appliances; 3.1 Eligibility
The Health Services Payment Act and Regulations, sec-
• chiropractic, podiatry, optometry, chiropody, osteopathy, tion 3, define eligibility for the Medical Services Insurance
naturopathy, and similar treatments; Plan. This Plan is designed to provide coverage for eligible
Prince Edward Island (PEI) residents. A resident is anyone
•
physiotherapy, psychology, and acupuncture except
legally entitled to remain in Canada and who makes his or
when provided in hospital;
her home and is ordinarily present on an annual basis for
• reversal of sterilization procedures; at least six months plus a day, in PEI.
• in vitro fertilization; All new residents must register with the Department
in order to become eligible. Persons who establish
•
services performed by another person when the permanent residence in PEI from elsewhere in Canada
supervising physician is not present or not available; will become eligible for insured hospital and medical
services on the first day of the third month following the
•
services rendered by a physician to members of month of arrival.
the physician’s own household, unless approval is
obtained from Health PEI; and Residents who are ineligible for insured hospital and
medical services coverage in PEI are those who are
• any other services that the Department may, upon the eligible for certain services under other federal or
recommendation of the negotiation process between provincial government programs, such as members of the
the Department, Health PEI and the Medical Society, Canadian Forces, inmates of federal penitentiaries, and
declare non-insured. clients of Workers’ Compensation or the Department of
Hospital services not covered by the Hospital Services Veterans Affairs’ programs.
Insurance Plan include private or special duty nursing at Ineligible residents may become eligible in certain
the patient’s or family’s request; preferred accommoda- circumstances. For example, members of the Canadian
tion at the patient’s request; hospital services rendered Forces become eligible on discharge or completion of
in connection with surgery purely for cosmetic reasons; rehabilitative leave. Penitentiary inmates become eligible
personal conveniences, such as telephones and upon release. In such cases, the province where the
televisions; drugs, biologicals and prosthetic and orthotic individual in question was stationed at the time of
appliances for use after discharge from hospital; and discharge or release, or release from rehabilitative leave,
dental extractions, except in cases where the patient would provide initial coverage during the customary
must be admitted to hospital for medical reasons with waiting period of up to three months. Parolees from
prior approval of Health PEI. penitentiaries will be treated in the same manner as
discharged prisoners.
36
New or returning residents must apply for health province, as allowed under section 11 of the Health
coverage by completing a registration application from Services Payment Act.
Health PEI. The application is reviewed to ensure that
all necessary information is provided. A health card Insured residents may be temporarily out of the country
is issued and sent to the resident within two weeks. for up to a 12 month period in some circumstances.
Renewal of coverage takes place every five years and
Students attending a recognized learning institution in an-
residents are notified by mail six weeks before renewal.
other country must provide proof of enrolment from the
The number of residents registered with the Medical educational institution on an annual basis. Students must
Services Insurance Plan in PEI as of March 31, 2016, notify Health PEI upon returning from outside the country.
was 146,930.
For PEI residents leaving the country for work purposes
3.2 Other Categories of Individuals for longer than one year, coverage ends the day the
Foreign students, tourists, transients or visitors to PEI do person leaves.
not qualify as residents of the province and are, therefore,
For Island residents travelling outside Canada, coverage
not eligible for hospital and medical insurance benefits.
for emergency or sudden illness will be provided at PEI
Temporary workers, refugees and Minister’s Permit rates only, in Canadian currency. Residents are respon-
holders are not eligible for hospital and medical insur- sible for paying the difference between the full amount
ance benefits. charged and the amount paid by the Department.

Prior approval is required from Health PEI before
4.0 PORTABILITY receiving non-emergency, out-of-province medical
4.1 Minimum Waiting Period or hospital services. Island residents seeking such
Insured persons who move to Prince Edward Island (PEI) required services may apply for prior approval through
are eligible for health insurance on the first day of the a PEI physician. Full coverage may be provided for (PEI
third month following the month of arrival in the province. insured) non-emergency or elective services, provided
the physician completes an application to Health PEI.
4.2 Coverage During Temporary Absences in Canada Prior approval is required from the Medical Director of
Residents absent each year for any reasons must reside Health PEI to receive out-of-country hospital or medical
in PEI for at least six months plus a day each in order to services not available in Canada.
be eligible for sudden illness and emergency services
while absent from the province, as allowed under section
11 of the Health Services Payment Act. A person, including 5.0 ACCESSIBILITY
a student, who is temporarily absent from the province
for up to 182 days in a 12 month period must notify 5.1 Access to Insured Health Services
Health PEI before leaving. Both of Prince Edward Island’s (PEI) hospital and
medical services insurance plans provide services on
PEI participates in the Hospital Reciprocal Billing uniform terms and conditions on a basis that does not
Agreements and the Medical Reciprocal Billing impede or preclude reasonable access to those services
Agreements along with other jurisdictions across Canada. by insured persons.
4.3 Coverage During Temporary Absences PEI has a publicly administered and funded health
Outside Canada system that guarantees universal access to medically
The Health Services Payment Act is the enabling legis- necessary hospital and physician services as required
lation that defines portability of health insurance during by the Canada Health Act.
temporary absences outside Canada, as allowed under
section 11. PEI recognizes that the health system must constantly
adapt and expand to meet the needs of our citizens.
Persons must reside in PEI for at least six months
plus a day each year in order to be eligible for sudden Several examples of initiatives from the 2015–2016
illness and emergency services while absent from the fiscal year include:

•
Youth with substance abuse and mental health Master Agreement between the PEI Medical Society,
issues can now access enhanced services with the on behalf of Island physicians, the Department of Health
opening of the new Youth Recovery Centre. Significant and Wellness, and Health PEI was effective April 1. 2010
investment has doubled bed capacity, the amount of to March 31, 2015. Negotiations for the new Master
group work and gender-specific programming. After Agreement are ongoing, and the current Master
care programs have also been implemented. Agreement remains in effect until a new agreement has
been ratified.
•
As PEI is primarily a rural province where a large
segment of the population resides outside the main The legislation governing payments to physicians and
service centres, local access to health services, dentists for insured services is the Health Services
including acute services delivered through communi- Payment Act.
ty hospitals and health centres, is important to small
communities. PEI continues to expand health Many physicians continue to work on a fee-for-service
infrastructure necessary to support health service basis; however, alternate payment plans have been
delivery in rural communities. This included a newly developed and some physicians receive salary, contract
renovated dialysis unit to improve access to high and sessional payments. Alternate payment modalities
quality dialysis care for Kings County patients, and are expanding and seem to be the preference for new
providing West Prince residents with access to new graduates. Currently, 64.7 per cent of PEI’s physicians (ex-
digital radiography suites. cluding locums and visiting specialists) are compensated
under an alternate payment method (non-fee-for-service)
• PEI implemented a new Generic Drug Plan which is as their primary means of remuneration.
open to all Islanders under age 65 with a valid PEI
health card who have no private drug coverage. This 5.3 Payments to Hospitals
caps the maximum price for more than 1,000 generics Payments (advances) to provincial hospitals and
in the drug formulary. This enhanced coverage community hospitals for hospital services are approved
complements coverage already offered via other for disbursement by the Department in line with cash
programs such as the Seniors’ Drug Cost Assistance requirements and are subject to approved budget levels.
Program, the High Cost Drug Program, and the
The usual funding method includes using a global budget
Catastrophic Drug Program.
adjusted annually to take into consideration increased
• The recruitment of a new cardiologist to the province costs related to such items as labour agreements,
has allowed for the addition of more heart health ser- drugs, medical supplies and facility operations.
vices that Islanders can access closer to home, includ-
ing transesophageal echocardiogram, stress echocar-
diogram and dobutamine stress echocardiogram. 6.0 RECOGNITION GIVEN TO
FEDERAL TRANSFERS
•
Emergency health services have been enhanced
by new computerized dispatch technology and an The Government of Prince Edward Island strives to
additional ambulance. This investment expands the recognize the federal contributions provided through
ground ambulance fleet, and improves services of- the Canada Health Transfer whenever appropriate. Over
fered in the ambulance. the past year, this has included reference in public
documents such as the Province of PEI 2015–2016
• PEI initiated the new Paramedics Providing Palliative Annual Budget and in the 2015–2016 Public Accounts,
Care At Home program. Under this program, paramed- which both were tabled in the Legislative Assembly and
ics can provide patients with pain and symptom man- are publicly available to Prince Edward Island residents.
agement at home, after hours.
It is also the intent of the Department of Health and
5.2 Physician Compensation Wellness to recognize this important contribution in its
A collective bargaining process is used to negotiate 2015–2016 Annual Report.
physician compensation. Bargaining teams are appointed
by both physicians and the government to represent their
interests in the process. The current five-year Physician
38
REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 7 7 7 7 7
Payments for insured health services ($) 183,647,900 192,480,600 197,008,800 206,026,400 210,797,200

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Payments to private for-profit facilities for 0 0 0 0 0
insured health services ($)

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments, out-patients ($) 5,136,948 6,566,417 7,616,353, 7,385,351 7,930,682

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016


Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of participating 325 348 320 335 357
physicians (#) 1
physicians (#)
physicians (#)

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 6,330,440 7,025,721 9,567,703 9,868,637 11,973,879

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services (#) 950 1,109 659 390 585
Total payments ($) 40,600 38,036 38,005 37,500 78,147

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services provided (#) 377 383 361 446 373
Total payments ($) 125,392 125,290 130,393 169,386 129,361
Prior to 2012-2013, the total does not include locums, visiting specialists, or other non-complement physicians.
1
2 For the 2011-2012 period, the reported data did not capture full comprehensive clinical payments. The reporting mechanism has been
corrected, and all relevant clinical payments are captured and presented from the 2012-2013 period and onwards.
40
CHAPTER 3 | NOVA SCOTIA
NOVA S C OT I A
The Nova Scotia Department of Health and The Department of Health and Wellness administers
Wellness’s vision and mission are: the Hospital Insurance Plan, which operates under the
Health Services and Insurance Act.
• Vision: Healthy People, Healthy Communities
The MSI Plan is administered and operated by an
for Generations authority consisting of the Department of Health and
Wellness and Medavie Blue Cross Incorporated.
•
Mission: Working together to achieve excel-
lence in health, healing and learning Section 8 of the Act gives the Minister of Health and
Wellness, with approval of the Governor in Council,
the power to enter into agreements and vary, amend
The health and wellness system includes the delivery of or terminate the same agreements with such person or
health care as well as the prevention of disease and injury persons as the Minister deems necessary to establish,
and the promotion of health and healthy living. implement and carry out the MSI Plan.
On April 1, 2015, Nova Scotia implemented amend- The Department of Health and Wellness and Medavie
ments to the Health Authorities Act. The amendments Blue Cross Incorporated entered into a service level
provided new roles for the Minister of Health and agreement, effective August 1, 2005. Under the agree-
Wellness and the health authorities, and the establishment, Medavie Blue Cross Incorporated is responsible
ment of the Nova Scotia Health Authority, which is a for operating and administering programs contained
consolidation of nine former district health authorities. under MSI, Pharmacare Programs and Health Card
The Minister of Health and Wellness is responsible for Registration Services.
providing leadership for the health system. The health
authorities (Nova Scotia Health Authority and the 1.2 Reporting Relationship
Izaak Walton Killam Health Centre — NSHA & IWK In the service level agreement, Medavie Blue Cross
respectively) are responsible for: governing, managing Incorporated is obliged to provide reports to the
and providing health services. Nova Scotia’s population Department under various Statements of Requirements
is aging and has much higher than average rates of for each Business Service Description as listed in the
chronic diseases such as cancers and diabetes. In contract. Medavie Blue Cross Incorporated is audited
response to the needs of the aging population, Nova every year on various areas of reporting.
Scotia has expanded its basket of publicly insured
services to include home care, long-term care, and Section 17(1)(i) of the Health Services and Insurance Act,
enhanced pharmaceutical coverage. and sections 11(1) and 12(1) of the Hospital Insurance
Regulations, under this Act, set out the terms for report-
Nova Scotia continues to be committed to the delivery ing by hospitals and hospital boards to the Minister of
of medically necessary services consistent with the Health and Wellness.
principles of the Canada Health Act.
Additional information related to health care in Nova The Auditor General audits all expenditures of the
Scotia may be obtained from the Department of Health Department of Health and Wellness. Under its service
and Wellness website at http://novascotia.ca/DHW. level agreement with the Department of Health and
Wellness, Medavie Blue Cross Incorporated provides
audited financial statements of MSI costs to the
1.0 PUBLIC ADMINISTRATION Department of Health and Wellness. The Auditor General
and the Department of Health and Wellness have the
1.1 Health Care Insurance Plan and Public Authority right to perform audits of the administration of the
Two plans cover insured health services in Nova Scotia: agreement with Medavie Blue Cross Incorporated.
the Hospital Insurance and the Medical Services
Insurance (MSI) Plans.

All long-term care facilities, home care and home support 2.0 COMPREHENSIVENESS
agencies are required to provide the Department of Health
and Wellness with annual audited financial statements. 2.1 Insured Hospital Services
The Nova Scotia Health Authority (NSHA) and the Izaak
Under section 34(5) of the Health Authorities Act, every Walton Killam (IWK) Health Centre — a women and chil-
hospital board is required to submit to the Minister of dren’s tertiary care hospital — deliver insured hospital
Health and Wellness, by July 1st each year, an audited services to both in-patients and out-patients in Nova Scotia.
financial statement for the preceding fiscal year.
Accreditation is not mandatory, but all facilities are
Under section 36(4) of the Health Authorities Act, a health accredited at a facility or district level. The enabling
authority is required to submit to the Minister of Health legislation that provides for insured hospital services in
and Wellness, no later than June 30th each year, an Nova Scotia is the Health Services and Insurance Act.
audited financial statement for the preceding fiscal year. Hospital Insurance Regulations were made pursuant to
the Health Services and Insurance Act.
1.4 Designated Agency
Medavie Blue Cross Incorporated administers and has the The Insured Health Services Act was passed in
authority to receive monies to pay physician accounts December 2012, but has not yet been proclaimed. It will
under the service level agreement with the Department replace the current Health Services and Insurance Act
of Health and Wellness. The rates of pay and specific which provides the statutory framework for health
amounts depend on the physician contract negotiated insurance programs in Nova Scotia. The new Act aims to
between Doctors Nova Scotia and the Department of modernize existing legislation (in place since 1973) and
Health and Wellness. it commits to the principles of the Canada Health Act
with the intent of ensuring equitable access to insured
The Department of Health and Wellness and the Office
health services.
of the Auditor General, have the right, under the terms
of the service level agreement, to audit all MSI and Under the Hospital Services Insurance Plan,
Pharmacare transactions. in-patient services include:
• accommodation and meals at the standard ward level;
Quikcard Solutions Incorporated (QSI) administers and
has the authority to receive monies to pay dentists • necessary nursing services;
under a service level agreement with the Department
of Health and Wellness. The tariff of dental fees is • laboratory, radiological and other diagnostic procedures;
negotiated between the Nova Scotia Dental Association
and the Department of Health and Wellness. • routine surgical supplies;
Medavie Blue Cross Incorporated is responsible for pro- • use of operating room(s), case room(s) and anaesthetic
viding approximately 60 regular, as well as ad hoc reports services;
to the Department pertaining to health card administration, •
use of radiotherapy and physiotherapy services for
physician claims activity, financial monitoring, provider in-patients, where available; and
management, audit activities and program utilization.
These reports are submitted on a monthly, quarterly, or • blood or therapeutic blood fractions.
annual basis. A complete list of reports can be obtained
from the Nova Scotia Department of Health and Wellness. Out-patient services include:
As part of an agreement with the Department of Health • laboratory and radiological examinations;
and Wellness, QSI also provides monthly, quarterly and
•
diagnostic procedures involving the use of radio-
annual reports with regard to dental programs in Nova
pharmaceuticals;
Scotia. This includes dental services provided in hospi-
tals as outlined in the Canada Health Act. These reports • electroencephalographic examinations;
address provider claims and payment, program utilization,
and audit. A complete list of reports can be obtained from •
use of occupational and physiotherapy facilities,
the Nova Scotia Department of Health and Wellness. where available;
42
• necessary nursing services; Additional services were added to the list of insured
physician services in 2015–2016. A complete list can be
• drugs, biologicals and related preparations; obtained from the Nova Scotia Department of Health
and Wellness. On an as needed basis, new specific fee
• blood or therapeutic blood fractions;
codes are approved that represent enhancements, new
•
hospital services in connection with most minor technologies or new ways of delivering a service.
medical and surgical procedures;
The addition of new fee codes, or adjustment to existing
• day-patient diabetic care; fee codes, to the list of insured physician services is
accomplished through a collaborative Department of
•
services provided by the Nova Scotia Hearing and Health and Wellness, Health Authority and Doctors
Speech Clinics, where available; Nova Scotia committee structure. Public consultations
are not generally undertaken when listing or delisting
• ultrasonic diagnostic procedures; insured medical services. Physicians wishing to have
• home parenteral nutrition, where available; and a new fee code added to the MSI Physician Manual
submit a formal application to the Fee Schedule Advisory
• haemodialysis and peritoneal dialysis, where available. Committee (FSAC) for review. Each request is thoroughly
researched. FSAC then makes a recommendation to the
Each year, the NSHA and the IWK Health Centre Master Agreement Steering Group (MASG) which either
submit business plans outlining budgets and priorities approves or denies the proposal. The MASG Committee
for the coming year to ensure safe and high quality is comprised of equal representation from Doctors Nova
access to care. Under the amended Health Authorities Scotia and the Department of Health and Wellness.
Act, business plans will be submitted on November If the fee is approved, Medavie Blue Cross Incorporated
1st every year and will be approved by the Minister of is directed to add the new fee to the schedule of insured
Health and Wellness. services payable by the MSI Plan.
2.2 Insured Physician Services 2.3 Insured Surgical-Dental Services
The legislation covering the provision of insured physician To provide insured surgical-dental services under the
services in Nova Scotia is the Health Services and Insurance Health Services and Insurance Act, dentists must
Act, sections 3(2), 5, 8, 13, 13A, 17(2), 22, 27 – 31, 35 and be registered members of the Nova Scotia Dental
the Medical Services Insurance Regulations. Association and must also be certified competent in
the practice of dental surgery. The Health Services and
As of March 31, 2016, 2,602 physicians were paid
Insurance Act is written so that a dentist may choose
through the Medical Services Insurance (MSI) Plan.
not to participate in the MSI Plan. To participate, a
Physicians retain the ability to opt in or out of the MSI dentist must register with MSI. A participating dentist
Plan. In order to opt out, a physician notifies MSI, who wishes to reverse election to participate must
relinquishing his or her billing number. MSI reimburses advise MSI in writing and is then no longer eligible to
patients who pay the physician directly due to opting submit claims to MSI. In 2015–2016, 28 dentists
out. As of March 31, 2016, no physicians had opted out. submitted claims through the MSI Plan for providing
insured surgical-dental services.
Insured services include those that are medically
necessary. Medically necessary may be defined as those Insured surgical-dental services must be provided in a
services provided by a physician to a patient with the health care facility. Insured services are detailed in the
intent to diagnose or treat physical or mental disease Department of Health and Wellness MSI Dentist Manual
or dysfunction, as well as those services generally (Dental-Surgical Services Program) and are reviewed
accepted as promoting health through prevention of annually through the Partnerships and Physician Services
disease or dysfunction. Services that are not medically Branch. Services under this program are insured when
necessary are not insured. Services explicitly deemed the condition of the patient is such that it is medically
as non-insured under the Health Services and Insurance necessary for the procedure to be done in a hospital and
Act or its Regulations remain uninsured regardless of the procedure is of a surgical nature.
individual judgments regarding the medical necessity.

Generally included as insured surgical-dental services •

diagnostic, preventive or other physician’s services
are orthognathic surgery, surgical removal of impacted available through the Nova Scotia Hospital Insurance
teeth, and oral and maxillofacial surgery. Requests for Program, the Department of Health and Wellness, or
an addition to the list of surgical-dental services are other government agencies;
accomplished through the Dental Association of Nova
Scotia who forwards a proposal to the Department of • services at the request of a third party;
Health and Wellness. Then, in consultation with experts
• provision of a prescription or a requisition for a diag-
in the field, the Department renders a decision on the
nostic or therapeutic service provided to a patient
addition of the procedure as an insured service. Public
without a clinical evaluation;
consultations are not undertaken during the consider-
ation of additions to the list of insured services. • physician’s services provided to their own families;
Insured services in the “Other extraction services” (rou- • services performed for cosmetic purposes only;
tine extractions) category are approved for the following
groups of patients: cardiac patients, transplant patients, •
group immunizations performed without receiving
immunocompromised patients, and radiation patients. preapproval by MSI;
This is the case only when patients are undergoing
• acupuncture;
active treatment in a hospital setting and the attendant
medical procedure must require the removal of teeth • electrolysis;
that would otherwise be considered routine extractions.
• reversal of sterilization;
2.4 Uninsured Hospital, Physician and
Surgical Dental Services • in vitro fertilization;
Uninsured hospital services include: • provision of travel vaccines;

• preferred accommodation at the patient’s request;
• newborn circumcision;
• telephones;
• release of tongue tie in newborn;
• televisions;
• removal of cerumen, except in the case of a febrile child;
•
drugs and biologicals ordered after discharge from
• treatment of warts or other benign conditions of the
hospital;
skin;
• cosmetic surgery;
•
comprehensive visits when there are no signs,
• reversal of sterilization procedures; symptoms or family history of disease or disability;
• in-vitro fertilization; •
services, supplies and other materials not part of
office overhead, including for example, photocopying
• procedures performed as part of clinical research trials; or other costs associated with transfer of records;
• services such as gastric bypass for morbid obesity, •

items such as drugs, dressings, and tray fees;
breast reduction/augmentation and newborn circum- physician’s advice by telephone, letter, fax or email,
cision (these services may be insured when approved with exceptions; and
as special consideration for medical reasons only); and
• mileage or travelling time.
•
services not deemed medically necessary that are
required by third parties, such as insurance companies. Major third party agencies currently purchasing medically
necessary health services in Nova Scotia include Workers’
Uninsured Physician Services include: Compensation and the Department of National Defence.
• services available to residents of Nova Scotia that are
covered under any statute or law of any other jurisdic- All residents of the province are entitled to services
tion, either within or outside of Canada; covered under the Health Services and Insurance Act. If
44
enhanced goods and services, such as foldable intraocu- following the month of their arrival. Persons moving
lar lens or fibreglass casts, are offered as an alternative, permanently to Nova Scotia from another country
the specialist or physician is responsible to ensure that are eligible on the date of their arrival in the province,
the patient is aware of their responsibility for the cost. provided they are Canadian citizens or hold “Permanent
Patients are not denied service based on their inability Resident” status as defined by Immigration, Refugees
to pay. The province provides alternatives to any of the and Citizenship Canada.
enhanced goods and services.
Individuals insured under the Worker’s Compensation
The Department of Health and Wellness carefully Act or any other Act in the Legislature or of the Parliament
reviews all patient complaints or public concerns that of Canada or under any statute or law of any other juris-
may indicate that the general principles of insured diction either within or outside of Canada are not eligible
services are not being followed. for MSI Coverage (such as members of the Canadian
Forces, federal inmates and some classes of refugees).
If a service or procedure is deemed by the Department Once individuals are no longer covered under any of the
of Health and Wellness not to be medically necessary, Acts, statutes or laws noted above, they are then eligible
it is removed from the physician fee schedule and will to apply for, and receive Nova Scotia health insurance
no longer be reimbursed to physicians as an insured coverage, provided that they are either a Canadian Citizen
service. Once a service has been de-insured, all or a permanent resident as defined by Immigration,
procedures and testing relating to the provision of Refugees and Citizenship Canada.
that service also become de-insured. The same also
applies to dental services and hospital services. Public In 2015–2016, the total number of residents registered
consultations are not undertaken during the determi- with the health insurance plan was 1,008,726.
nation of medical necessity and de-listing of insured
services. The last time there was any significant 3.2 Other Categories of Individuals
de-insurance of services was in 1997. Other individuals may be eligible for insured health care
services in Nova Scotia if they meet specific eligibility
criteria listed below:
3.0 UNIVERSALITY Immigrants: Persons moving from another country to
3.1 Eligibility live permanently in Nova Scotia are eligible for health
Eligibility for insured health care services in Nova Scotia care on the date of arrival if they arrive as a permanent
is outlined under section 2 of the Hospital Insurance resident as determined by Immigration, Refugees and
Regulations made pursuant to section 17 of the Health Citizenship Canada.
Services and Insurance Act. All residents of Nova Scotia
Non-Canadians married to Canadian Citizens or Permanent
are eligible. A resident is defined as anyone who is
Residents (copy of marriage certificate required), who
legally entitled to stay in Canada and who makes his or
possess the required documentation from Immigration,
her home and is ordinarily present in Nova Scotia.
Refugees and Citizenship Canada indicating they have
In 2015-2016, a person was considered to be “ordinarily applied for permanent residency, will be eligible for
present” in Nova Scotia if the person: coverage on the date of arrival in Nova Scotia (if applied
prior to their arrival to Nova Scotia ), or the date of appli-
• makes his or her permanent home in Nova Scotia; cation for permanent residency (if applied after their
arrival in Nova Scotia).
• is physically present in Nova Scotia for at least 183
days in any calendar year (short term absences under Convention refugees or persons in need of protection who
30 days, within Canada, are not monitored); and possess the required documentation from Immigration,
Refugees and Citizenship Canada indicating they have
• is a Canadian citizen or “Permanent Resident” as de- applied for permanent residency will be eligible for cover-
fined by Immigration, Refugees and Citizenship Canada. age on the date of application for permanent residency.
Persons moving to Nova Scotia from another Canadian In 2015–2016, there were 41,196 permanent residents
province will normally be eligible for Medical Services registered with the health care insurance plan.
Insurance (MSI) on the first day of the third month

Refugees: Refugees are eligible for MSI once they have 4.0 PORTABILITY
been granted permanent residency status by Immigration,
Refugees and Citizenship Canada, or if they possess 4.1 Minimum Waiting Period
either a work permit or study permit. Persons moving to Nova Scotia from another Canadian
province or territory will normally be eligible for Medical
Work Permits: Persons moving to Nova Scotia from out- Services Insurance (MSI) on the first day of the third
side the country who possess a work permit can apply month following the month of their arrival.
for coverage on the date of arrival in Nova Scotia, provided
they will be remaining in Nova Scotia for at least one full 4.2 Coverage During Temporary Absences in Canada
year. A declaration must be signed to confirm that the The Interprovincial Agreement on Eligibility and Portability
worker will not be outside Nova Scotia for more than is followed in all matters pertaining to the portability of
31 consecutive days, unless required in the course of insured services.
employment. MSI coverage is extended for a maximum
of 12 months at a time. Each year, a copy of their Generally, the Nova Scotia MSI Plan provides coverage
renewed immigration document must be presented for residents of Nova Scotia who move to other prov-
and a declaration signed. Dependents of such persons, inces or territories for a period of three months, per the
who are legally entitled to remain in Canada, are granted Eligibility and Portability Agreement. Students and their
coverage on the same basis. dependents, who are temporarily absent from Nova
Scotia and in full-time attendance at an educational
Once coverage has terminated, the person is to be institution, may remain eligible for MSI on a yearly basis.
treated as never having qualified for health services To qualify for MSI, the student must provide to MSI a
coverage as herein provided and must comply with the letter directly from the educational institution which
above requirements before coverage will be extended states that they are registered as a full-time student.
to them or their dependents. MSI coverage will be extended on a yearly basis
pending receipt of this letter.
In 2015–2016, there were 3,269 individuals with
Employment Authorizations covered under the health Workers who leave Nova Scotia to seek employment
care insurance plan. elsewhere will still be covered by MSI for up to 12 months,
provided they do not establish residence in another
Study Permits: Persons moving to Nova Scotia from province or territory. Services provided to Nova Scotia
another country and who possess a Study Permit will residents in other provinces or territories are covered by
be eligible for MSI on the first day of the thirteenth reciprocal agreements. Nova Scotia participates in the
month following the month of their arrival, provided they Hospital Reciprocal Billing Agreement and the Medical
have not been absent from Nova Scotia for more than Reciprocal Billing Agreement. Quebec is the only province
31 consecutive days, unless required in the course of that does not participate in the Medical Reciprocal Billing
their studies. MSI coverage is extended for a maximum Agreement. Nova Scotia pays for services provided by
of 12 months at a time and only for services received Quebec physicians to Nova Scotia residents at Quebec
within Nova Scotia. Each year, a copy of their renewed rates if the services are insured in Nova Scotia. The ma-
immigration document must be presented and a jority of such claims are received directly from Quebec
declaration signed. Dependents of such persons, physicians. In-patient hospital services are paid through
who are legally entitled to remain in Canada, will be the interprovincial reciprocal billing arrangement at the
granted coverage on the same basis once the student standard ward rate of the hospital providing the service.
has gained entitlement. Nova Scotia pays the host province rates for insured
services in all reciprocal billing situations.
In 2015–2016, there were 1,467 individuals with Student
Authorizations covered under the health care insurance The total amount paid by the plan in 2015–2016 for
plan. in-patient and out-patient hospital services received in
other provinces and territories was $33,197,140.
As of August 1, 2014, Nova Scotia residents receive out of

province coverage for vacation for one additional month.
This allows Nova Scotia residents to have a vacation out-
46
side of the province for seven months in each calendar Persons who engage in employment (including volunteer,
year and continue to be eligible for MSI. Nova Scotia missionary work or research) outside Canada which does
residents who are vacationing outside of Nova Scotia for not exceed 24 months are still covered by MSI, providing
not more than seven months in a calendar year will be the person has already met the residency requirements.
deemed a resident if the following conditions are met:
The total amount spent in 2015–2016 for insured
(a)The resident communicates to MSI of their absence in-patient services provided outside of Canada was
from Nova Scotia; $1,409,302. Nova Scotia does not cover out-patient
services out-of-country.
(b) The resident does not establish residency outside
Nova Scotia; and 4.4 Prior Approval Requirement
Prior approval must be obtained for elective services
(c) New or returning residents must be physically present outside the country. Application for prior approval is
in Nova Scotia for at least 183 days prior to the absence. made to the Medical Director of the MSI Plan by a
specialist in Nova Scotia on behalf of an insured
4.3 Coverage During Temporary Absences
resident. The medical consultant reviews the terms and
Outside Canada
conditions and determines whether or not the service
Nova Scotia adheres to the Agreement on Eligibility and
is available in the province, or if it can be provided in
Portability for dealing with insured services for residents
another province or only out-of-country. The decision
temporarily outside Canada. Provided a Nova Scotia
of the medical consultant is relayed to the patient’s
resident meets eligibility requirements, out-of-country
referring specialist. If approval is given to obtain service
services will be paid, at a minimum, on the basis of the
outside the country, the full cost of that service will be
amount that would have been paid by Nova Scotia for
covered under MSI.
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.
5.0 ACCESSIBILITY
As of August 1, 2014, Nova Scotia residents receive out
5.1 Access to Insured Health Services
of country coverage for vacation for one additional month.
Section 3 of the Health Services and Insurance Act
This allows Nova Scotia residents to have a vacation out-
states that subject to this Act and the Regulations, all
side of the country for seven months in each calendar
residents of the province are entitled to receive insured
year and continue to be eligible for MSI. Nova Scotia
hospital services from hospitals on uniform terms and
residents who are vacationing outside of Nova Scotia for
conditions. As well, all residents of the province are
not more than seven months in a calendar year will be
insured on uniform terms and conditions in respect of
deemed a resident if the following conditions are met:
the payment of insured professional services to the
(a) The resident communicates to MSI of their absence extent of the established tariff. There are no user charges
from Nova Scotia; or extra charges allowed under the plan.
(b) The resident does not establish residency outside Nova Scotia continually reviews access situations across
Nova Scotia; and Canada to ensure equity of access. In areas where
improvement is deemed necessary, depending on the
(c) New or returning residents must be physically present province’s financial situation, extra funding is generally
in Nova Scotia for at least 183 days prior to the absence. allocated to that need.
Students and their dependents who are temporarily Eight Collaborative Emergency Centers (CECs) are
absent from Nova Scotia and in full-time attendance at now open to provide Nova Scotians living in smaller
an educational institution outside Canada may remain communities expanded access to primary health care,
eligible for MSI on a yearly basis. To qualify for MSI, same day or next day access to appointments and 24/7
the student must provide to MSI a letter obtained from access to emergency care. Emergency Department
the educational institution that verifies the student’s closures have been significantly reduced at CEC sites.
attendance there in each year for which MSI coverage The Department has worked with system partners to
is requested. address several other areas of health care access.

The province has transitioned from nine district health organizations for service delivery.
authorities to one provincial health authority – the Nova
Scotia Health Authority. This new structure took effect in An Act to Provide for Health Authorities and Community
April 1, 2015. Health Boards was given Royal Assent on October 3,
2014. The Act provided for the consolidation of the nine
Alternative Payment Plans for physicians continued to district health authorities into one provincial health
be implemented and/or expanded to improve recruit- authority, the Nova Scotia Health Authority (NSHA). The
ment in rural and hard-to-fill areas, improving access to IWK will remain as a separate health authority. The
primary health care in those communities. NSHA and IWK will be required to work collaboratively
in delivering services to Nova Scotians. The NSHA and
5.2 Physician Compensation the IWK are responsible for overseeing the delivery
The Health Services and Insurance Act, RS Chapter 197 of health services in the province of Nova Scotia, and
governs payment to physicians and dentists for insured are fully accountable for explaining their decisions on
services. Physician payments are made in accordance the community health plans through their business plan
with a negotiated agreement between Doctors Nova submissions to the Department of Health and Wellness.
Scotia (the sole bargaining agent for physicians) and
the Nova Scotia Department of Health and Wellness. Section 10 of the Health Services and Insurance Act
Fee-for-service is still the most prevalent method of and sections 9 through 13 of the Hospital Insurance
payment for physician services; however, there has Regulations define the terms for payments by the
been significant growth in the number of alternative Minister of Health and Wellness to hospitals for insured
payment arrangements in place in Nova Scotia. hospital services.
In the 1997–1998 fiscal year, about nine per cent of doc- In 2015-2016, there were 2,926 hospital beds in Nova
tors were paid solely through alternative funding. In Scotia (3.10 beds per 1,000 population). Department
2015–2016, approximately 22 per cent of physicians of Health and Wellness direct expenditures for insured
were remunerated exclusively through alternative fund- hospital services operating costs were $1,720,856,746.
ing. Approximately 58 per cent of physicians in Nova
Scotia receive all or a portion of their remuneration
through alternative funding mechanisms such as aca- 6.0 RECOGNITION GIVEN TO
demic funding agreements with clinical departments for FEDERAL TRANSFERS
the provision of clinical, academic, administrative and
research services; alternative payment plans for individ- In Nova Scotia, the Health Services and Insurance Act
ual physicians and groups used mostly in rural areas; acknowledges the federal contribution regarding the
and other funding programs such as emergency agree- cost of insured hospital services and insured health
ments and sessional funding. services provided to provincial residents. The residents
of Nova Scotia are aware of ongoing federal contribu-
Payment rates for dental services in the province are tions to Nova Scotia health care through the Canada
negotiated between the Department of Health and Health Transfer (CHT) as well as other federal funds
Wellness and the Nova Scotia Dental Association through press releases and media coverage.
following a process similar to physician negotiations.
Dentists are generally paid on a fee-for-service basis. The Government of Nova Scotia also recognized the
Paediatric dentists at the IWK Health Centre receive federal contribution under the CHT in various published
remuneration through an Academic Funding Plan. documents, including the following documents:
5.3 Payments to Hospitals • Public Accounts 2014–2015 released July 30, 2015;
The Department of Health and Wellness establishes and
budget targets for health care services. It does this
by receiving business plans from the provincial Health • Budget Estimates and Supplementary Detail 2015–
Authority (Nova Scotia Health Authority), the IWK 2016 released April 9, 2015.
Health Centre and other non-district health authority
organizations. Approved provincial estimates form
the basis on which payments are made to these
48
REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number as of March 31st (#) 994,018 998,763 1,000,124 1,001,708 1,008,726

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 35 35 35 35 35
Payments for insured health services ($)1 1,593,552,159 1,619,915,286 1,679,289,646 1,735,234,990 1,720,856,746

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
providing health services (#) 2
Payments to private for-profit facilities for not applicable not applicable not applicable not applicable not applicable
insured health services($)

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total number of claims, in-patient (#) not available not available not available not available not available
Total payments, in-patient ($) 2,176,921 1,104,701 1,242,889 777,019 1,409,302
Total number of claims, out-patient (#) not applicable not applicable not applicable not applicable not applicable
Total payments, out-patients ($) not applicable not applicable not applicable not applicable not applicable
1 This reflects payments made to the public facilities noted for indicator 2 above.
2 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.


Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
physicians (#)
physicians (#)
Number of non-participating not applicable not applicable not applicable not applicable not applicable
physicians (#)

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 8,297,188 8,512,631 8,607,696 8,884,002 9,304,321

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 185,142 110,695 173,452 157,344 72,025

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services provided (#) 3
7,228 7,007 7,391 8,492 8,591
Total payments ($) 4 1,338,592 1,397,223 1,356,416 1,442,994 1,401,379
3 Total services includes block funded dentists.

4 Total payments does not include block funded dentists.
50
CHAPTER 3 | NEW BRUNSWICK
NE W B RU N S W I CK
1.0 PUBLIC ADMINISTRATION and provides accounting, audit and consulting services
in accordance with responsibilities and authority set out
1.1 Health Care Insurance Plan and Public Authority in the Financial Administration Act.
In New Brunswick, the formal name for Medicare is the
Medical Services Plan. The Minister of Health (Minister) Monitoring and Compliance Team: This team is
is responsible for operating and administering the plan tasked with managing compliance with the Medical
by virtue of the Medical Services Payment Act and its Payment Services Act and Regulations, as well as the
Regulations. The Act and Regulations set out who is Negotiated Fee Schedule.
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 2.0 COMPREHENSIVENESS
defines which Medicare services are covered and which 2.1 Insured Hospital Services
are excluded. It also stipulates the type of agreements Legislation providing for insured hospital services
the Department may enter into. As well, it specifies includes the Hospital Services Act, section 9 of Regulation
the rights of a medical practitioner; how the amounts 84 – 167, and the Hospital Act. Under Regulation 84 – 167
to be paid for medical services will be determined; of the Hospital Services Act, New Brunswick residents
how assessment of accounts for medical services may are entitled to the following insured hospital services.
be made; and confidentiality and privacy issues as they
relate to the administration of the Act. Insured in-patient services include: accommodation
and meals; nursing; laboratory/diagnostic procedures;
1.2 Reporting Relationship drugs; the use of facilities (e.g., surgical, radiotherapy,
The Medicare – Insured Services Branch and the Medicare – physiotherapy); and services provided by professionals
Eligibility and Claims Branch of the Department are within the facility.
mandated to administer the Medical Services Plan. The
Minister reports to the Legislative Assembly through Insured out-patient services include: laboratory and
the Department’s annual report and through regular diagnostic procedures; mammography; and the hospital
legislative processes. component of available out‑patient services for main-
taining health, preventing disease and helping diagnose
The Regional Health Authorities Act establishes the or treat any injury, illness or disability, excluding those
regional health authorities (RHAs) and sets forth the related to the provision of drugs or third party diagnostic
powers, duties, and responsibilities of the same. requests.
The Minister is responsible for the administration of the
Act, provides direction to each RHA, and may delegate 2.2 Insured Physician Services
additional powers, duties or functions to the RHAs. The Medical Services Payment Act and corresponding
Regulations provide for insured physician services. As of
1.3 Audit of Accounts March 31, 2016 there were 1,652 participating
Three groups have a mandate to audit the Medical physicians in New Brunswick. No physicians rendering
Services Plan. health care services elected to opt out of the Medical
The Office of the Auditor General: In accordance with Services Plan. When a physician opts out of Medicare,
the Auditor General Act, the Office of the Auditor they must complete the specified Medicare claim form
General conducts the external audit of the accounts of and indicate the amount charged to the patient. The
the Province of New Brunswick, which includes the beneficiary then seeks reimbursement by certifying on
financial records of the Department. The Auditor General the claim form that the services have been received and
also conducts management reviews on programs as he forwarding the claim form to Medicare. The charges must
or she sees fit. not exceed the Medicare tariff. If the charges are in excess
of the Medicare tariff, the practitioner must inform
The Office of the Comptroller: The Comptroller is the the beneficiary before rendering the service that:
chief internal auditor for the Province of New Brunswick

•
they have opted out and charge fees above the Code Service Description
Medicare tariff;
8123 Bariatric Roux-en-y
•
in accepting services under these conditions, the 8124 Bilio pancreatic diversion
patient waives all rights to Medicare reimbursement; 8127 Abdominal wall reconstruction with
prosthesis (with component separation)
• the patient is entitled to seek services from another
practitioner who participates in the Medical Services 8126 Insertion or removal of permanent
Plan; and peritoneal dialysis catheter by laparoscopy
8120 Endoscopic treatment of cricopharyngeal
• the physician must obtain a signed waiver from the diverticulum by endoscopy
patient on the specified form and forward the form to
8138 Surgical management of penile fracture
Medicare.
8139 Pancreatic cyst gastrostomy or
The services which residents are entitled to under duodenostomy by endoscopy
Medicare include: 8125 Removal or insertion of implantable loop
recorder
a) the medical portion of all medically required services
rendered by medical practitioners; and 8130 Transcatheter Aortic Valve Implantation -
Cardiac Surgery
b) certain surgical-dental procedures when performed 8128 Transcatheter Aortic Valve Implantation -
by a physician or a dental surgeon in a hospital. Interventional Radiology
A physician or the Department may request the addition 8129 Transcatheter Aortic Valve
of a new service. All requests are considered by the New Implantation - Interventional Cardiology
Service Items Committee, which is jointly managed by 8158 Injection and Ingestant Challenge test
the New Brunswick Medical Society and the Department. 8159 Each additional challenge test, same visit,
The decision to add a new service is usually based on add
conformity to the definition of “medically necessary” and 8160 Resuscitation, if required, add
whether the service is considered generally acceptable
practice (not experimental) within New Brunswick and/or 8146 Talc Slurry Pleurodesis Thoracostomy,
Canada. Considerations under the term “medically neces- solo procedure
sary” include services required for maintaining health, 8155 Insertion of central venous catheter via
preventing disease and/or diagnosing or treating an injury, puncture of a proximal vein
illness or disability. No public consultation process is used. 8622 Regional lymphadenectomy (paracaval and/
or para-aortic nodes and/or pelvic nodes),add
In 2015–2016 the following services were added to
8623 Pelvic lymphadenectomy, add
the list of insured services:
8624 Regional lymphadenectomy (internal iliac
Code Service Description nodes and/or obturator nodes), add
8173 Cystocoele or rectocoele repair with mesh 8707 Compression Sutures
(includes enterocoele) 8084 Retrograde Enteroscopy Through Stoma
8174 Cystocoele and rectocoele repair with mesh 8085 Double Balloon Small Bowel Enteroscopy
(includes enterocoele) 8079 Pachymetry – Measuring Corneal Thickness
8175 Suburethral Sling using prosthetic material 8080 Optical Coherence Tomography, Professional
to include TVT, SPARC,TOT and similar
8081 Optical Coherence Tomography, Technical
procedures - female only, add
8625 Radiofrequency Ablation for Barett’s
8176 Transvaginal sacropinous colopexy with
Esophagus – Dysplasia – Halo 360 Halo 90
mesh (to include enterocoele)
8086 Intracoronary Ultrasound, Add
8177 McCall suture or McCall culdoplasty, add
8087 Coronary Pressure Derived Fractional Flow
8122 Gastric banding
Reserve, Add
52
Code Service Description • correction of inverted nipple;

8146 Talc Slurry Pleurodesis Thracostomy, • breast augmentation;
Solo Procedure
847 Extramural Palliative Care Home Visit to a • otoplasty for persons over the age of eighteen;
Previously Admitted Patient to the Program •
removal of minor skin lesions, except where the
848 Extramural Palliative Care Home Visit to a lesions are, or are suspected to be, pre-cancerous;
Previously Admitted Patient to the Program,
Emergency Visit • abortion, unless the abortion is performed in a hospital
facility approved by the jurisdiction in which the hospital
With regards to gender confirming surgeries, New facility is located;
Brunswick insured this service effective August 11,
2016. Therefore, it will be reflected in next year’s report. • surgical assistance for cataract surgery unless such
assistance is required because of risk of procedural
2.3 Insured Surgical-Dental Services failure, other than risk inherent in the removal of the
Schedule 4 of Regulation 84–20 under the Medical cataract itself, due to existence of an illness or other
Services Payment Act identifies the insured surgical- complication;
dental services that can be provided by a qualified dental
practitioner in a hospital, providing the condition of the •
medicines, drugs, materials, surgical supplies or
patient requires services to be rendered in a hospital. prosthetic devices.
In addition, a general dental practitioner may be paid to • vaccines, serums, drugs and biological products listed
assist another dentist for medically required services in sections 106 and 108 of New Brunswick Regulation
under some conditions. In addition to Schedule 4 of 88-200 under the Health Act;
Regulation 84–20, oral maxillofacial surgeons (OMS) have
• advice or prescription renewal by telephone which is
added access to approximately 300 service codes in the
not specifically provided for in the Schedule of Fees;
Physician Manual and can admit or discharge patients
and perform physical examinations, including those • examination of medical records or certificates at the
performed in an out-patient setting. OMSs may also see request of a third party, or other services required by
patients for consultation in their office. hospital regulations or medical by-laws;
As of March 31, 2016, there were just over 100 OMSs and • dental services provided by a medical practitioner or
dentists registered in New Brunswick; in 2015 – 2016, 19 an oral and maxillofacial surgeon;
provided services insured under the Medical Services Plan.
•
services that are generally accepted within New
2.4 Uninsured Hospital, Physician and Brunswick as experimental or that are provided as
Surgical-Dental Services applied research;
Uninsured hospital services include: take-home drugs;
third-party requests for diagnostic services; visits to ad- • services that are provided in conjunction with, or in
minister drugs; vaccines; sera or biological products; relation to, the services referred to above;
televisions and telephones; preferred accommodation at
the patient’s request; and hospital services directly relat- • testimony in a court or before any other tribunal;
ed to services listed under Schedule 2 of the Regulation
• immunization, examinations or certificates for purpose
under the Medical Services Payment Act. Services are not
of travel, employment, emigration, insurance or at the
insured if provided to those entitled under other statutes.
request of any third party;
The services listed in Schedule 2 of New Brunswick
• services provided by medical practitioners or oral and
Regulation 84–20 under the Medical Services Payment
maxillofacial surgeons to members of their immediate
Act are specifically excluded from the range of entitled
family;
medical services under Medicare. They are as follows:
• psychoanalysis;
• elective plastic surgery or other services for cosmetic
purposes;

• electrocardiogram (E.C.G.) where not performed by a services is based on the conformity of the service to the
specialist in internal medicine or paediatrics; definition of “medically necessary,” a review of medical
service plans across the country, and the previous use
•
laboratory procedures not included as part of an of the particular service. Once a decision to de-insure is
examination or consultation fee; reached, the Medical Services Payment Act dictates that
the government may not make any changes to the
• refractions;
Regulation until the advice and recommendations of the
•
services provided within the province by medical New Brunswick Medical Society are received or until the
practitioners, oral and maxillofacial surgeons or dental period within which the Society was requested by the
practitioners for which the fee exceeds the amount Minister to furnish advice and make recommendations
payable under Regulation; has expired. Subsequent to receiving their input and res-
olution of any issues, a regulatory change is completed.
• the fitting and supplying of eye glasses or contact Physicians are informed in writing following notification
lenses; of approval. The public is usually informed through a media
release. No public consultation process is used.
• trans-sexual surgery;
In 2015–2016, no services were removed from the
• radiology services provided in the province by a private insured services list.
radiology clinic;
• acupuncture;
3.0 UNIVERSALITY
• complete medical examinations when performed for
3.1 Eligibility
the purposes of periodic check-up and not for medically
Sections 3 and 4 of the Medical Services Payment Act
necessary purposes;
and Regulation 84–20 define eligibility for the health
• circumcision of a newborn; care insurance plan in New Brunswick. Residents are
required to complete a Medicare application and provide
• reversal of vasectomies; proof of identity, proof of residency, proof of Canadian
citizenship or a valid Canadian immigration document.
• second and subsequent injections for impotence; A resident is defined as a person lawfully entitled to be,
• reversal of tubal ligations; or to remain, in Canada, who makes his or her home
and is ordinarily present in New Brunswick, but does
• intrauterine insemination; not include a tourist, transient, or visitor to the province.
• bariatric surgery unless the person has a body mass As of March 31, 2016, there were 754,522 persons
index of 40 or greater or of 35 or greater but less than registered in New Brunswick.
40, as well as obesity-related comorbid conditions; and
All persons entering or returning to New Brunswick
•
venipuncture for purposes of taking blood when (excluding children adopted from outside Canada) have
performed as a stand-alone procedure in a facility that a waiting period before becoming eligible for Medicare
is not an approved hospital facility. coverage. Coverage commences on the first day of the
third month following the month of arrival.
Dental services not specifically listed in Schedule 4
of the Dental Schedule are not covered by the Plan. Exceptions are as follows:
Those listed in Schedule 2 are considered the only non- •
Dependents of Canadian Armed Forces personnel
insured medical services. There are no specific policies or or their spouses moving from within Canada to New
guidelines, other than the Act and Regulations, to ensure Brunswick are entitled to first day coverage under the
that charges for uninsured medical goods and services program, provided they are deemed to have estab-
(e.g., fibreglass casts), provided in conjunction with an lished permanent residency in New Brunswick.
insured health service, do not compromise reasonable
access to insured services. • Immigrants or Canadian residents moving or returning
to New Brunswick from outside of Canada are entitled
The decision to de-insure physician or surgical-dental to first day coverage, provided they are deemed to have
54
established permanent residency in the province. Proper the month permanent residency has been established.
documentation is required from Immigration, Refugees, The three month waiting period is legislated under New
and Citizenship Canada. Decisions on coverage and Brunswick’s Medical Services Payment Act. Refer to
residency are reviewed on a case-by-case basis. section 3.1 of this submission for exceptions.
Residents who were not eligible for Medicare 4.2 Coverage During Temporary Absences in Canada
coverage during this reporting period included: The legislation that defines portability of health
• regular members of the Canadian Armed Forces; insurance during temporary absences in Canada is the
Medical Services Payment Act, Regulation 84 – 20,
• inmates at federal institutions; sub-sections 3(4) and 3(5).
• temporary residents; Medicare coverage may be extended upon request
in the case of temporary absences to:
• a family member who moves from another province to
New Brunswick before other family members move. •
students in full-time attendance at an educational
institution outside New Brunswick;
•
persons who have entered New Brunswick from
another province to further their education and who • residents temporarily working in another jurisdiction;
are eligible to receive coverage under the medical and
services plan of that province; and
• residents whose employment require them to travel
• non-Canadians who are issued certain types of Canadian outside the province.
authorization permits (e.g., a Student Authorization).
Students
Persons who are discharged or released in New Brunswick Those in full-time attendance at a university or other
from the Canadian Armed Forces, or a federal peniten- approved educational institution, who leave the province
tiary, become eligible for coverage on the date of their to further their education in another province, will be
discharge or release. An application must be completed granted coverage for a 12 month period that is renew-
and signed, and have proof of Canadian citizenship, able, provided the following terms are met:
proof of residency and the official date of release.
• Medicare is contacted once every 12 months;
3.2 Other Categories of Individuals
Non-Canadians who may be issued an immigration per- • permanent residency is not established outside New
mit that would not normally entitle them to Medicare Brunswick; and
coverage are eligible provided that they are legally mar-
ried to, living in a common-law relationship with or are a • health insurance coverage is not received elsewhere.
dependent of an eligible New Brunswick resident and
Residents
possess a valid immigration permit. They are required to
Residents temporarily employed in another province
provide an updated immigration document prior to the
or territory, are granted coverage for up to 12 months
previous permit expiring.
provided the following terms are met:
Children born out of country to Canadian Citizens will
• permanent residency is not established outside New
take the eligibility criteria of the parent upon return to
Brunswick; and
the Province.
• health insurance coverage is not received elsewhere.
Foreign students are considered visitors to the Province
and are not eligible for coverage. New Brunswick has formal agreements for reciprocal
billing arrangements of insured hospital services with all
provinces and territories. In addition, New Brunswick
4.0 PORTABILITY has reciprocal agreements with all provinces, except
Quebec, for the provision of insured physician services.
4.1 Minimum Waiting Period
Services provided by Quebec physicians to New Brunswick
A person is eligible for New Brunswick Medicare
residents are paid at Quebec rates provided the service
coverage on the first day of the third month following
delivered is insured in New Brunswick. The majority of

such claims are received directly from Quebec physicians. status (e.g., letter from employer or contract confirming
Any claims submitted directly by a patient are reimbursed that frequent travel is necessary outside the province;
to the patient. a letter from the resident detailing their permanent
residence as New Brunswick and the frequency
4.3 Coverage During Temporary Absences of their return to the province; a copy of their New
Outside Canada Brunswick driver’s license; if working outside Canada,
The legislation that defines portability of health insur- a copy of resident’s immigration documents that allow
ance during temporary absences outside Canada is them to work outside the country); and
the Medical Services Payment Act, Regulation 84 – 20,
subsections 3(4) and 3(5). • the worker must return to New Brunswick during their
off-time.
Eligibility for New Brunswick residents temporarily
absent outside of Canada is determined in accordance Mobile Worker status is assigned for a maximum of two
with the Medical Services Payment Act. years, after which the resident must reapply and submit
documentation to confirm a continuation of Mobile
Residents temporarily employed outside Canada are Worker status.
granted coverage for 182 days. This may be extended up
to 12 months within a three year period upon approval Contract Workers
from the Director of Medicare Eligibility and Claims. Any New Brunswick resident accepting a contract out-
Exceptions to this are mobile and contract workers. of-country must supply the following information and
documentation:
Coverage for any absence over 212 days for vacation
purposes requires approval from the Director of Medicare • a letter of request from the New Brunswick resident
Eligibility and Claims. This approval can only be for up with their signature, detailing their absence, Medicare
to 12 months in duration and will only be granted once number, address, departure and return dates, destina-
every three years. tion, forwarding address, and reason for absence; and
New Brunswick residents exceeding the 12 month • a copy of a contractual agreement between employee
extension have to reapply for New Brunswick Medicare and employer indicating start and end dates of employ-
upon their return to the province. In this instance, cases ment.
are reviewed on a case by case basis. Depending on the
circumstances, some cases may be eligible for first day Contract Worker status is assigned up to a maximum
coverage while others who have been away from the of two years. Any further requests for contract worker
province slightly beyond the 12 month period may be status must be forwarded to the Director of Medicare
given a grace period. Eligibility and Claims for approval on an individual basis.
Insured residents who receive insured emergency Students

services out-of-country are eligible to be reimbursed Those in full-time attendance at a university or other
$100 per day for in-patient stays and $50 per out-patient approved educational institution in another country
visit. The insured resident is reimbursed for physician will be granted coverage for a 12 month period that is
services associated with the emergency treatment renewable, provided they comply with the following:
at New Brunswick rates. The difference in rates is the
•
proof of enrolment must be provided from the
patient’s responsibility.
educational institution on an annual basis;
Mobile Workers
• Medicare must be contacted once every 12 months;
Mobile Workers are residents whose employment
requires them to travel outside the province (e.g., • permanent residency cannot be established outside
pilots). The following guidelines must be met to receive New Brunswick; and
Mobile Worker designation.
• health insurance coverage cannot be received elsewhere.
• applications must be in writing;
• documentation is required as proof of Mobile Worker Medicare may cover out-of-country services that are not
56
available in Canada on a pre-approval basis only. Residents 5.0 ACCESSIBILITY

may opt to seek non-emergency out-of-country services;
however, they are responsible for assuming the total cost. 5.1 Access to Insured Health Services
New Brunswick’s health care system delivers equitable,
New Brunswick residents may be eligible for reimburse- quality care to the public it serves. New Brunswick does
ment if they receive elective medical services outside not permit user fees for insured health services as
the country, provided the following requirements are met: defined by the Canada Health Act.
•
the required service or equivalent, or an alternate Access in a resident’s official language of choice is not a
service must not be available in Canada; limiting factor, regardless of where a resident receives
services in the province.
• the service must be rendered in a hospital listed in the
current edition of the American Hospital Association 5.2 Physician Compensation
Guide to the Health Care Field (guide to United States Payments to physicians and dentists are governed under
hospitals, health care systems, networks, alliances, the Medical Services Payment Act, Regulations 84–20,
health organizations, agencies and providers); 93–143 and 2002–53.
• the service must be rendered by a medical doctor; The methods used to compensate physicians for provid-
and ing insured health services in New Brunswick are fee-
for-service, salary and sessional, or alternate payment
• the service must be an accepted method of treatment
mechanisms that may include a blended system.
recognized by the medical community and be regarded
by the medical community as scientifically proven in 5.3 Payments to Hospitals
Canada. Experimental procedures are not covered. The legislative authorities governing payments to hospi-
tal facilities in New Brunswick are the Hospital Act,
If the above requirements are met, it is mandatory to
which governs the administration of hospitals, and the
request prior approval from Medicare in order to receive
Hospital Service Act, which governs the financing of
coverage. A physician, patient or family member may
hospitals. The Regional Health Authorities Act provides
request prior approval to receive these services outside
for delivery and administration of health services in
the country, accompanied by supporting documentation
defined geographic areas within the province.
from a Canadian specialist or specialists.
The Department mainly distributes available funding
Out-of-country insured services that are not available
to New Brunswick’s regional health authorities (RHAs)
in Canada, are non-experimental, and receive prior
through a Current Service Level approach. The funding
approval are paid in full. Often the amount payable is
base of the RHA from the previous year is the starting
negotiated with the provider by Europ Assistance —
point, to which approved salary increases and a global
Global Corporate Solutions on the province’s behalf.
inflator for non-wage items are added. This applies to all
Heamodialysis is exempt from the out-of-country cover- clinical services provided by hospital facilities, as well
age policy. Patients are required to obtain prior approval as support services (e.g., administration, food services,
and Medicare will reimburse the resident at a rate equiv- etc.). Funding for the Extra-Mural Program (home care)
alent to the inter-provincial rate of $472 per session. is also part of the RHA base.
Prior approval is also required to refer patients to Funding for Service New Brunswick (SNB), a shared ser-
psychiatric hospitals and addiction centres outside vices agency that manages the information technology,
the province because they are excluded from the materials management, laundry and clinical engineering
Interprovincial Reciprocal Billing Agreement. A request components of the hospital facilities in New Brunswick,
for prior approval must be received by Medicare from is also based on the Current Service Level approach.
the Addiction Services or Mental Health branches of the Facilicorp NB, the previous entity responsible for shared
Department. services, was transferred to SNB as of Oct 1, 2015.
Any requests for funding for new programs or services

are submitted to the Deputy Minister of Health for ap-
proval. Funding for approved new programs or services

are based on requirements identified through discussions 6.0 RECOGNITION GIVEN TO

between Department of Health and RHA staff. These
amounts are added to the RHA funding base once there FEDERAL TRANSFERS
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.
REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 58 59 60 61 62

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
providing insured health services (#)1
Payments to private for-profit facilities 0 0 0 0 0
for insured health services ($)1

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total number of claims, out-patient (#) 1,285 1,080 1,004 882 1,119
1 There are no private for-profit facilities operating in New Brunswick.
58

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of participating physicians (#) 2 1,618 1,640 1,635 1,631 1,652
Number of opted-out physicians (#) 0 0 0 0 0
Number of non-participating physicians (#) 0 0 0 0 0
Total payments for services provided 543,148,047 581,432,080 554,684,438 577,131,145 582,756,568
by physicians paid through all payment
methods ($)3
Total payments for services provided by 306,092,105 307,211,084 306,411,123 325,012,469 359,837,199
physicians paid through fee-for-service ($)

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 13,221,951 15,089,061 22,127,528 18,284,577 21,436,423

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 635,020 397,912 315,078 246,305 278,398

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of participating dentists (#) 4 23 20 21 18 19
Total payments ($) 712,367 663,654 718,088 618,627 498,480
2 These are the number of physicians with an active physician status on March 31st of each year.
3 The total payment for all payment methods is a preliminary figure and includes budgeted amounts for alternate funding plans.
4 These are the number of dentists and oral maxillofacial surgeons (OMSs) participating in New Brunswick’s Medical Services Plan during
each fiscal year. Out of the 100+ dentists and OMSs registered, these billed the Medical Services Plan.

CHAPTER 3 | QUEBEC
Q UE B E C
1.0 PUBLIC ADMINISTRATION Other insured services are include the following: Me-
chanical, hormonal or chemical contraception services;
1.1 Health Insurance Plan and Public Authority surgical sterilization services (including tubal ligation or
The Quebec Hospital Insurance Plan is administered vasectomy); reanastomosis of the fallopian tubes or vas
by the Ministère de la Santé et des Services Sociaux deferens; and extraction of a tooth or root when the
(MSSS) (the Quebec Department of Health and Social patient’s health status makes hospital services necessary.
Services).
The MSSS administers an ambulance transportation pro-
Quebec’s health and drug insurance plans are adminis- gram that is free of charge to persons aged 65 and older.
tered by the Régie de l’assurance maladie du Québec
(the Board or Régie), a public body established by the In addition to basic insured health services, the Régie
provincial government that reports to the Minister of also covers optometric services for people who are
Health and Social Services. under age 18 or 65 and over, and as a last resort for finan-
cial assistance recipients; dental care for children age 10
1.2 Reporting Relationships and under and last resort financial assistance recipients;
The Public Administration Act (R.S.Q., c. A-6.01) sets and acrylic dental prostheses for last resort financial
forth government criteria for preparing reports on the assistance recipients.
planning and performance of public authorities, including
the MSSS and the Régie. It also covers, for Quebec residents within the meaning
of the Health Insurance Act (R.S.Q. c. A 29) who meet
1.3 Audit of Accounts the eligibility criteria for each program, prostheses,
The plans (the Quebec Hospital Insurance Plan and the orthotics, orthopaedic appliances, walking and posture
Quebec health and drug insurance plans) are adminis- aids; hearing aids and assistive listening devices; visual
tered by the public authorities on a non-profit basis. All aids; external breast prostheses; ocular prostheses;
books and accounts are audited by the auditor general permanent ostomy appliances and compression clothing
of the province. for people with lymphedema.
With regard to drug insurance, since January 1, 1997, the

2.0 COMPREHENSIVENESS Régie has covered, in addition to recipients of last resort
financial assistance and persons aged 65 and over,
2.1 Insured Hospital Services Quebec residents who otherwise would not have
Insured in-patient services include the following: access to a private drug insurance plan. In 2015–2016, the
Standard ward accommodation and meals; necessary drug insurance plan covered 3.6 million insured persons.
nursing services; routine surgical supplies; diagnostic
services; use of operating rooms, delivery rooms and 2.2 Insured Physician Services
anaesthetic facilities; medication; prosthetic and orthotic Services insured under this plan include medical and
devices that can be integrated with the human body; surgical services that are provided by physicians partici-
biological products and related preparations; use of radio- pating in the plan and are medically necessary.
therapy and physiotherapy facilities; and services
delivered by hospital staff. Family planning services set forth by legislation and
provided by a physician are insured, as are assisted
Out-patient services include the following: Clinical reproduction services set forth by Regulation.
services for psychiatric care; electroshock, insulin and
behaviour therapies; emergency care; minor surgery (day 2.3 Insured Surgical-Dental Services
surgery); radiotherapy; diagnostic services; physiotherapy; Services insured under this plan include surgery per-
occupational therapy; inhalation therapy, audiology, formed by dental surgeons and specialists in oral and
speech therapy and orthoptic services; and other ser- maxillo-facial surgery, in a prescribed hospital centre or
vices or examinations required under Quebec legislation. university institution.
60
CHAPTER 3 | QUEBEC
2.4 Uninsured Hospital, Physician and humans, unless these services are delivered in a hospital
Surgical-Dental Services centre; ultrasonography, unless this service is delivered
Uninsured hospital services include plastic surgery for in a hospital centre or, for obstetrical purposes, in a local
purely cosmetic purposes, a private or semi-private room community service centre (CLSC) recognized for that
at the patient’s request, televisions, telephones, drugs purpose; optical tomography of the eyeball and confocal
and biological products ordered after discharge from hos- scanning laser ophthalmoscopy of the optic nerve, unless
pital, and services for which the patient is covered under these services are delivered in a facility maintained by
the Act respecting industrial accidents and occupational an institution that operates a hospital or are delivered in
diseases or other federal or provincial legislation. association with the delivery, by intravitreal injection, of
an antiangiogenic drug for the treatment of age-related
The following services, among others, are not insured: macular degeneration; any radiological or anaesthetic
any examination or service not related to a process of service provided by a physician if required for the pro-
curing or preventing illness; psychoanalysis of any kind, vision of an uninsured service, with the exception of a
unless such service is delivered in a facility maintained dental service provided in a hospital centre or, in the
by an institution authorized for such purpose by the case of radiology, if required by a person other than a
Minister of Health and Social Services; any service physician or dentist; any sex-reassignment surgery, un-
provided solely for aesthetic purposes; any refractive less it is provided on the recommendation of a physician
surgery, except where there is documented failure in specializing in psychiatry and is provided in a hospital
respect of corrective lenses and contact lenses for astig- centre recognized for this purpose; and any services that
matism of more than 3.00 diopters or anisometropia of are not related to pathology and that are delivered by a
more than 5.00 diopters measured from the cornea; physician to a patient between 18 and 65 years of age,
any consultation by telecommunication or by correspon- unless that individual is the holder of a claim booklet, for
dence, with the exception of telehealth services within colour blindness or a refractive error, in order to provide or
the meaning of the Act respecting health services and renew a prescription for eyeglasses or contact lenses;
social services; any service delivered by a profession- any assisted reproduction services, with the exception
al to his or her spouse or children; any examination, of artificial insemination, including ovarian stimulation
expert appraisal, testimony, certificate or other formality services within the meaning of the Act.
required for legal purposes or by a person other than
the one who has received an insured service, except
in certain cases; any visit made for the sole purpose of 3.0 UNIVERSALITY
obtaining the renewal of a prescription; any examina-
tion, vaccination, immunization or injection where the 3.1 Eligibility
service is provided to a group or for certain purposes; Registration with the hospital insurance plan is not re-
any service delivered by a professional on the basis of an quired. Registration with the Régie de l’assurance maladie
agreement or contract with an employer, association or du Québec is sufficient to establish an individual’s eligi-
body; any adjustment of eyeglasses or contact lenses; bility. Any individual residing or staying in Quebec as
any surgical extraction of a tooth or dental fragment per- defined in the Health Insurance Act must be registered
formed by a physician, unless such a service is provid- with the Régie de l’assurance maladie du Québec to be
ed in a hospital centre in certain cases; all acupuncture eligible for hospital services.
procedures; injection of sclerosing substances and the
examination performed at that time; mammography
Inmates in federal penitentiaries are not covered by the
used for detection purposes, unless this service is re-
Quebec Health Insurance Plan.
quired by medical prescription in a place designated
by the Minister to a recipient 35 years of age or older, Certain categories of residents, notably permanent res-
provided that the person has not been so examined for idents under the Immigration Act and persons returning
one year; thermography, tomodensitometry, magnetic to live in Canada, become eligible under the plan follow-
resonance imaging and use of radionuclides in vivo in ing a waiting period of up to three months. Persons from

CHAPTER 3 | QUEBEC
another country receiving last resort financial assistance they report directly, or employed by the federal govern-
benefits are eligible upon registration. ment and posted outside Quebec, also retain their status
as a resident of the province. The same is true of persons
Canadian Forces personnel and their family members who remain outside the province for 183 days or more,
posted to Quebec from another Canadian province or but less than 12 months within a calendar year, provided
territory who have a status permitting them to settle such an absence occurs only once every seven years.
there are eligible on the date of their arrival. Those who
have not acquired Quebec resident status, and inmates The costs of insured services provided by health profes-
of federal penitentiaries, become insured the day they sionals to an insured person in another province or
are discharged or released. territory of Canada are reimbursed for the amount
actually paid or at the rate that would have been paid by
Immediate coverage is provided for certain seasonal the Régie for such services in Quebec, whichever is less.
workers, repatriated Canadians, persons from outside However, Quebec has negotiated a permanent arrange-
Canada who are living in Quebec under an official bursary ment with Ontario to pay Ottawa medical specialists at
or internship program of the Ministère de l’Éducation the Ontario fee rate for specialized services that are not
(the Quebec Department of Education), persons from available in the Outaouais region. This agreement came
outside Canada who are eligible under an agreement or into effect on November 1, 1989. The Régie covers the
accord reached with a country or an international organi- amount it would have paid for the same services in
zation, and refugees. Quebec. The Centre intégré de services de santé et de
services sociaux de l’Outaouais (Outaouais integrated
Persons from outside Canada who have work permits
health and social services centre) pays the difference
and are living in Quebec for the purpose of holding an
between the cost invoiced by Ontario and the amount
office or employment for a period of more than six
initially reimbursed by the Régie. A similar agreement
months may be eligible for the plan following a waiting
was signed in December 1991 between the Centre de
period of up to three months.
santé de Témiscaming (Temiscaming Health Centre) and
the North Bay Regional Health Centre.
4.0 PORTABILITY Costs for hospital services provided in another province
4.1 Minimum Waiting Period or territory of Canada are paid in accordance with the terms
Persons settling in Quebec after moving from another and conditions of the Hospital Reciprocal Billing Agreement
province of Canada can obtain coverage under the Quebec regarding hospital insurance agreed to by the provinces
Health Insurance Plan when they cease to be entitled and territories of Canada. These costs are paid either at
to benefits from their province of origin, provided they the established per diem for hospitalization in a standard
register with the Régie and meet certain conditions. ward or in intensive care proposed by the host province
and approved by all the provinces and territories or, in cases
4.2 Coverage During Temporary Absences in Canada of outpatient services or expensive procedures, at the
If living outside Quebec in another province or territory approved interprovincial rates. Services that are excluded
for 183 days or more, and provided they notify the Régie from interprovincial agreements but covered under the
of this, students and full-time unpaid trainees may retain provincial program are reimbursed at the rate in force.
their status as residents of Quebec: students for a max-
imum of four consecutive calendar years, and full-time Insured persons who leave Quebec to settle in another
unpaid trainees for a maximum of two consecutive province or territory of Canada are eligible for coverage
calendar years. for up to three months after leaving the province.
This is also the case for persons living in another province 4.3 Coverage During Temporary Absences
or territory who are temporarily employed or working on Outside Canada
contract there. Their resident status can be maintained For residents who receive insured services in a hospital
for no more than two consecutive calendar years. outside Canada, the Régie reimburses the cost of such
services in case of emergency or sudden illness to a
Persons directly employed or working on contract out- maximum of $100 (CAD) per day if the patient was
side Quebec for a company or corporate body with its hospitalized (including in the case of day surgery) or to a
headquarters or a place of business in Quebec, to which maximum of $50 (CAD) per day for outpatient services.
62
CHAPTER 3 | QUEBEC
However, haemodialysis treatments are covered to a An insured person who moves permanently from Quebec to
maximum of $220 (CAD) per treatment. In these cases, another country ceases to be insured on the day of departure.
the Régie covers the associated professional services at
the lowest cost, either the amount actually paid or what 4.4 Prior Approval Requirement
would have been paid by the Régie for the same ser- To receive full reimbursement for medical and hospital
vices in Quebec. The services must be delivered in a services elsewhere in Canada or in another country, a
hospital or hospital centre recognized and accredited by written request signed by two physicians with expertise
the appropriate authorities. No reimbursements are in the field of the pathology of the person on whose
made for nursing homes, spas or similar establishments, behalf the request is made must first be sent to the
or for any services that are experimental in nature. Régie. The request must be accompanied by a summary
of the insured person’s medical file; describe the special-
Costs for insured services provided by physicians, ized services required by the insured person; attest to
dentists, maxillo-facial surgeons and optometrists are the unavailability of said services in Quebec or Canada;
reimbursed at the rate that would have been paid by the and contain information about the treating physician
Régie to a health professional recognized in Quebec, and the name and address of the hospital where the
up to the amount of the expenses actually incurred. services are to be provided. Following an evaluation of
All professional services insured by the Quebec Health the request by the Régie, authorization to receive the
Insurance Plan are reimbursed at the Quebec rate, usually services is either given or denied. No authorization will
in Canadian funds. be given if the service is available in Quebec or if it is an
experimental service.
Students, unpaid trainees, Quebec government officials
posted abroad and employees of non-profit organizations
working in international aid or co-operation programs 5.0 ACCESSIBILITY
recognized by the Minister of Health and Social Services
can remain insured while living outside Quebec. They 5.1 Access to Insured Health Services
must contact the Régie to determine their eligibility. If Everyone has the right to receive adequate health care
the Régie grants them special status, they receive full services without any kind of discrimination. In Quebec,
reimbursement for hospital costs in case of emergency the Quebec Health Insurance Act does not allow for the
and 75 per cent reimbursement in other cases. Howev- imposition of user charges. It also forbids anyone from
er, when such persons go on holiday outside their place requiring or receiving any payment from a person for
of study, training or work, this coverage is no longer in fees for an insured service, except in cases prescribed
force: regular coverage for hospital services applies. by Regulations or outlined in an agreement and under
the conditions indicated in it.
Persons employed directly by a company or corporate body
with its headquarters or a place of business in Quebec Improving access to health and social services for the
to which they report directly, or persons employed by the population is a government priority. In order to achieve
federal government and posted outside Quebec, can, under this objective in a more difficult economic and budgetary
certain conditions, remain covered by the Quebec Health environment, Quebec has undertaken a transformation
Insurance Plan while living outside Canada. of the health and social services network (the network)
and its governance. On April 1, 2015, Quebec adopted An
Hospital services provided outside Quebec in cases of Act to modify the organization and governance of the health
emergency or sudden illness for persons working for a and social services network, in particular by abolishing
company or corporate body with its headquarters or the regional agencies (chapter O-7.2) (LMRSSS).
a place of business in Quebec to which they report
directly, or for persons employed by the federal govern- The purpose of the LMRSSS is to:
ment and posted outside Quebec, are reimbursed in full • simplify access to health and social services and the
by the Régie, and reimbursed at 75 per cent in other cases. continuum of care for the population;
In general, residents of Quebec who are working or • foster greater fluidity within establishments through
studying abroad are covered by the plan in effect in the efficient integration of patient services;
that country when the stay falls under a social security
agreement reached between the Minister of Health and • ensure better clinical patient information flow between
Social Services and the country in question. care providers; and

CHAPTER 3 | QUEBEC
• increase the network’s efficiency and effectiveness by • CHU de Québec — Université Laval;
meeting the challenge of population-based responsibility.
• Institut universitaire de cardiologie et de pneumologie
This reorganization builds on that initiated in 2004–2005 de Québec — Université Laval;
with the adoption of Bills 25 and 83, the purpose of
which was to create local service networks (RLS) in • Centre hospitalier de l’Université de Montréal;
each health and social services region and to merge
• McGill University Health Centre;
institutions (CH, CLSC and CHSLD) to form health and
social services centres (CSSS) at the heart of the local • Centre hospitalier universitaire Sainte-Justine;
service networks. The present transformation goes even
further by creating, for most health and social services • Institut de cardiologie de Montréal;
regions, an integrated health and social services centre
• Institut Philippe-Pinel de Montréal;
or an integrated university health and social services
centre. These new institutions, which are the result of • five public institutions not targeted by the Act to modify
the merger of the health and social services agency the organization and governance of the health and
and the public institutions in a given region, generally social services network, in particular by abolishing the
encompass all the health missions (CH, CHSLD, CLSC, regional agencies (chapter O-7.2) (LMRSSS) that serve
CR and CPEJ). a Northern or Aboriginal population; and
On March 31, 2016, the health and social services net- • 17 public institutions attached to an integrated centre.
work had 143 institutions: 51 public and 92 private. These institutions were not merged with other institu-
These institutions administer 1,663 facilities or physical tions under the LMRSSS but are administered by the
spaces that provide health and social services to the board of the integrated centre to which they are attached.
Quebec population.
On March 31, 2016, Quebec had 46 facilities operating
The 51 public institutions are administered by 33 president- as acute-care hospital centres. On that date, 19,686
CEOs or CEOs. They include integrated health and social general and specialized-care beds were allotted to these
services centres (CISSS) and integrated university facilities. According to the most recent available data,
health and social services centres (CIUSSS), hereafter between April 1, 2014 and March 31, 2015, there were
referred to as integrated centres, as well as grouped 774,474 admissions for short-term care (including new-
institutions and other institutions that have been neither borns and long-term care patients treated in short-term
grouped nor merged. care units) and 369,369 admissions for day surgery in
Each of the 22 integrated centres is the result of the Quebec hospitals. These admissions accounted for
merger of all public institutions in a given health and 5,813,358 patient days.
social services region, or part of a region, with the health Quebec also has four integrated university health
and social services agency, as the case may be. Nine of networks (réseaux universitaires intégrés de santé or
the 22 integrated centres call themselves “centre intégré RUIS) that promote cooperation, complementarity and
universitaire de santé et de services sociaux” (CIUSSS) integration of the care, teaching and research missions
because they are located in a health and social services of the health facilities and universities with which they are
region in which a university offers a complete predoctor- affiliated. In addition to the services provided by public
al program of study in medicine or because they operate facilities, the population also has access to the services
a centre designated as a university institute in the field of private facilities which offer accommodation, long-term
of social services. care and other services.
The 29 remaining public institutions are distributed Family medicine groups (FMGs) were established in
as follows: 2003–2004. A FMG is a group of doctors working as a
• seven university hospital centres (CHU) and university team and in close cooperation with nurses and other
institutes (IU) that are not attached to an integrated CISSS and CIUSSS health professionals to provide
centre but to the MSSS and offer specialized or ultra- services ranging from disease prevention, health and
specialized services beyond the boundaries of their wellness assessment and patient monitoring to diagno-
health and social service region, namely: sis and treatment of acute and chronic problems. These
64
CHAPTER 3 | QUEBEC
services also include medical consultations with and Payments to hospital centres in other provinces or out-
without an appointment, seven days a week, and an side Canada for hospital services totaled approximately
adapted response to persons whose health status $216.37 million.
requires special arrangements for access to services.
The Programme de financement et de soutien profes-
sionnel pour les GMF (FMG financial and professional
support program) came into force on November 16,
2015. It offers financial and professional support tailored
to the realities of clinicians and the needs of patients,
and introduces equitable, patient-centred funding,
added professional support (in addition to nursing per-
sonnel, social workers, pharmacists and other health
professionals), a more balanced service offer, less bur-
densome administrative procedures, and mandatory
use of electronic health records. Implementation of the
Program is part of a comprehensive review of front-line
service access that also includes a review of the net-
work clinic model. On March 31, 2016, Quebec had 263
accredited FMGs and 52 network clinics. Forty-three of
these network clinics are also FMGs.
5.2 Physician Compensation

Physicians are remunerated in accordance with the
negotiated fee schedule. The Minister may enter into an
agreement with the organizations representing any
class of health professional. This agreement may pre-
scribe a different rate of compensation for medical ser-
vices in a territory where the number of professionals is
considered insufficient.
While the majority of physicians practice within the provin-

cial plan, Quebec allows two other options: professionals
who withdraw from the plan and practice outside the
plan, but agree to be remunerated according to the pro-
vincial fee schedule; and non-participating professionals
who practice outside the plan, with no reimbursement
from the Régie going to either them or their patients.
According to the most recent data available, in 2015–2016,

the Régie paid an estimated $7.3 billion for professional
services provided to Quebec residents. Professional
services (including reimbursements to insured persons
and payments to professionals) received outside Quebec
were estimated at $50.7 million.

The Minister of Health and Social Services funds hospitals
through payments directly related to the cost of the
insured services provided.
The payments made in 2015–2016 to institutions operat-

ing as hospital centres for insured health services pro-
vided to residents of Quebec totaled nearly $11.9 billion.

CHAPTER 3 | ONTARIO
O NTAR I O
Ontario has one of the largest and most complex 1.2 Reporting Relationship
publicly-funded health care systems in the world. The Health Insurance Act stipulates that the Minister of
Health and Long-Term Care is responsible for the admin-
Administered by the province’s Ministry of Health
istration and operation of OHIP, and is Ontario’s public
and Long-Term Care (MOHLTC), Ontario’s health authority for the purposes of the Canada Health Act.
care system was supported by over $51 billion
(including capital) in spending during 2015 – 2016. The Local Health System Integration Act, 2006 (LHSIA)
requires each LHIN to prepare an annual report on its
affairs and operations for the previous fiscal year. The
Government of Ontario’s Agency and Appointments
Directive requires that every Ontario operational service
1.0 PUBLIC ADMINISTRATION agency (including LHINs) prepare an annual report. The
Minister is required to table the reports in the Legislative
1.1 Health Care Insurance Plan and Public Authority Assembly of Ontario.
Ontario Health Care and Health Care Planning
MOHLTC has an accountability agreement with each
The Ontario Health Insurance Plan (OHIP) is administered LHIN that includes obligations, measures and targets.
on a non-profit basis by the Ministry of Health and Long- The agreements also include funding allocations by
Term Care (MOHLTC). OHIP was established in 1972 and sector, for example, long-term care homes and hospi-
is continued under the Health Insurance Act, Revised tals. LHSIA provides the LHINs with the authority to fund
Statutes of Ontario, 1990, c. H-6, to provide insurance defined health service providers and to enter into service
in respect of the cost of insured services provided to accountability agreements with health service providers.
Ontario residents (as defined in the Health Insurance Act)
in hospitals and health facilities, and by physicians and 1.3 Audit of Accounts
other health care practitioners. Every year the Auditor General of Ontario reports on the
results of their examination of government resources
The MOHLTC provides services to the public through and administration. The Auditor General’s report is tabled
programs such as health insurance, drug benefits, by the Speaker of the Legislative Assembly, usually in
assistive devices, forensic mental health and supportive the fall, at which time it becomes available to the public.
housing, long‑term care, home care, community and Audit reports on select areas of the MOHLTC chosen
public health, and health promotion and disease for review by the Auditor General are included within
prevention. It also regulates hospitals and nursing this annual report, the last of which was released on
homes, operates medical laboratories, and coordinates November 30, 2016.
emergency health services.
MOHLTC’s accounts are published annually in the Public
Local Health Integration Networks (LHINs) were estab- Accounts of Ontario. The 2015–2016 Public Accounts of
lished under the Local Health System Integration Act, Ontario were tabled and released on October 6, 2016.
2006 (LHSIA) to help improve Ontarians’ health through
better access to high-quality health services, coordinated
health care, and effective and efficient management of 2.0 COMPREHENSIVENESS
the health system at the local level. Since April 1, 2007,
the LHINs have had responsibility for funding, planning
Insured in-patient and out-patient hospital services in
and integrating health care services at the local level.
Ontario are prescribed under the Health Insurance Act,
This includes services delivered by hospitals, community
and Regulation 552 under the Act.
care access centres, long-term care homes, community
health centres, community support services, and mental Insured in-patient hospital services include medically
health and addictions agencies. required: use of operating rooms, obstetrical delivery
rooms and anaesthetic facilities; necessary nursing
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CHAPTER 3 | ONTARIO
services; laboratory, radiological and other diagnostic physician offices, community health centres, hospitals,
procedures together with the necessary interpretations mental health facilities, licensed independent health
for the purpose of maintaining health, preventing disease facilities, and long-term care homes.
and assisting in the diagnosis and treatment of any injury,
illness or disability; drugs, biologicals and related prepa- In general terms, insured physician services include: diag-
rations; and accommodation and meals at the standard nosis and treatment of medical disabilities and conditions;
ward level. medical examinations and tests; surgical procedures;
maternity care; anaesthesia; radiology and laboratory ser-
Insured out-patient services include medically required: vices in approved facilities; and immunizations, injections
laboratory, radiological and other diagnostic procedures; and tests.
use of radiotherapy, occupational therapy, physiotherapy
and speech therapy facilities, where available; use of diet Physicians must be registered to practise medicine
counselling services; use of the operating room and in Ontario by the College of Physicians and Surgeons
anaesthetic facilities; surgical supplies; necessary nurs- of Ontario, and be located in Ontario when rendering
ing service; supply of drugs, biologicals, and related the service.
preparations (subject to some exceptions); certain other
During 2015-2016, most physicians submitted claims
specified services such as the provision of certain equip-
for all insured services rendered to insured persons
ment, to haemophiliac patients for use at home; and
directly to OHIP, and a small number of physicians billed the
certain specified home-administered drugs.
insured person. Physicians who do not bill OHIP directly
Hospital services are not specifically listed in Regulation are commonly referred to as having opted out of the
552 in the Health Insurance Act, rather, the Regulation Plan. When a physician has opted out of the Plan the
lists broad categories of services. This permits the physician bills the patient an amount not exceeding the
Regulation to cover new medical and technological amount payable for the service under the Schedule of
advances as they become accepted standards of practice. Benefits — Physician Services (this was permitted on
a grandparented basis following proclamation of the
Adding a new broad category of hospital services to the Commitment to the Future of Medicare Act in 2004). The
list of insured services covered by the Ontario Health patient then recoups that amount from the Plan.
Insurance Plan (OHIP) requires a regulatory change.
Regulatory changes are approved by Cabinet and gener- There were approximately 30,177 physicians who sub-
ally there is a public consultation process by way of mitted claims to OHIP in 2015-2016. This figure includes
Ontario’s Regulatory Registry. physicians submitting both fee-for-service claims and
physicians included in an alternative payment plan who
No regulation changes to add hospital services were submitted tracking or shadow-billed claims. In 2015-
completed in fiscal year 2015-2016. 2016, there were 21 opted-out physicians in Ontario.
2.2 Insured Physician Services The Schedule of Benefits — Physician Services is regular-

Insured physician services are prescribed under the ly reviewed and revised to reflect current medical practice
Health Insurance Act and Regulations under the Act. and new technologies. New services may be added, ex-
isting services revised, or obsolete services removed
Under Regulation 552 to the Health Insurance Act, a through regulatory amendment. This process involves
service provided by a physician in Ontario is an insured consultation with the Ontario Medical Association.
service if it is medically necessary; referred to in the
Schedule of Benefits — Physician Services; and rendered In 2015-2016, there were several changes made to the
in such circumstances or under such conditions as spec- Schedule, including changes to achieve savings that were
ified in the Schedule of Benefits — Physician Services. implemented April 1, 2015, June 1, 2015, October 1, 2015,
Physicians provide medical, surgical and diagnostic ser- as well as other changes implemented October 26, 2015,
vices, including primary health care services. Services December 21, 2015 and March 1, 2016, that included the
are provided in a variety of settings, including: private implementation of a new Fertility Program.

CHAPTER 3 | ONTARIO
2.3 Insured Surgical-Dental Services Complaints regarding charges for insured services are
In accordance with the Canada Health Act, certain investigated under the Commitment to the Future of
surgical-dental services are prescribed as insured services Medicare Act (CFMA) Program. Investigations are
under Regulation 552 in the Health Insurance Act and opened to determine whether any patient was charged
listed in the Schedule of Benefits — Dental Services. The for an insured service; this would include whether a
Health Insurance Act authorizes OHIP to pay for a limited block fee included charges for an insured service, or if
number of procedures when the procedure is medically a charge for an enhanced service was, in fact, for an
necessary, and it is medically necessary that the insured insured service. If it is found that a patient was charged
services be performed in a public hospital graded under for an insured service, the MOHLTC ensures that
the Public Hospitals Act as Group A, B, C or D, by a dental patients are reimbursed in accordance with provisions
surgeon who has been appointed to the dental staff of the of the CFMA.
public hospital.
Generally, insured dental services include: oral and 3.0 UNIVERSALITY

maxillo-facial surgery that normally would be required
to be performed in a hospital; root resection and apical 3.1 Eligibility
curettage procedures when performed in association with Section 11 of the Health Insurance Act specifies that every
other insured dental procedures; and dental extractions person who is a resident of Ontario is entitled to become
when performed in a hospital for the safety of high risk an insured person under the Ontario Health Insurance
patients and if prior approval is obtained from the Ministry Plan (OHIP) upon application. In order to be considered
of Health and Long-Term Care (MOHLTC). an Ontario resident, Regulation 552 under the Health
Insurance Act, with a few exceptions that are noted in the
With respect to insured surgical-dental services, MOHLTC Regulation, requires that a person must:
consults with the Ontario Dental Association in making
changes to the Schedule of Benefits — Dental Services. • hold Canadian citizenship or an immigration status as
prescribed in Regulation 552;
Surgical-Dental Services • make his or her primary place of residence in Ontario;
Uninsured hospital services include but are not limited to:
•
subject to some limited exceptions, be physically
private or semi-private accommodation unless prescribed
present in Ontario for at least 153 days in any 12-month
by a physician, oral-maxillofacial surgeon or midwife;
period; and
telephones and televisions; charges for certain private-
duty nursing; and provision of medications for patients • for most new and returning residents, be physically
to take home from hospital, with prescribed exceptions. present in Ontario for 153 of the first 183 days following
the date residence is established in Ontario. For ex-
Section 24 of Regulation 552 details some specified
ample, a person cannot be away from the province for
physician and supporting services that are not insured
more than 30 days in the first six months of residency.
services.
Individuals who are not eligible for OHIP coverage are
Uninsured physician services include: services that
those who do not meet the definition of a resident, such
are not medically necessary; services not listed in the
as tourists, transients, visitors to the province and those
Schedule of Benefits — Physician Services; and services
who do not hold an immigration or other similar status
that are excluded from insured services under Section
as defined in the Regulation. Services that a person is
24 of Regulation 552.
entitled to receive under federal legislation are not
Dental services provided in dentists’ offices are not insured services, for example, those provided to
insured and payment is the responsibility of the federal penitentiary inmates and Canadian Forces
individual patient. Dental services not specifically listed members. Services that a person is entitled to receive
in the Dental Schedule are also not insured including under the Workplace Safety and Insurance Act are not
such services as prosthetic restorations (fixed bridges insured services in Ontario.
and dentures) for the replacement of teeth, orthodontic
When it is determined that a person is not eligible, or is
treatment, fillings and crowns.
no longer eligible, for OHIP coverage, a request may be
68
CHAPTER 3 | ONTARIO
made to the Ministry of Health and Long-Term Care Holders of Temporary Resident Permits: A Temporary
(MOHLTC) to review the decision. Anyone may request Resident Permit is issued to an individual by IRCC when
that the MOHLTC review the denial of their OHIP eligi- there are compelling reasons to admit an individual into
bility by making a request in writing to the OHIP Eligibility Canada who would otherwise be inadmissible under the
Review Committee. Those who are not satisfied with federal Immigration and Refugee Protection Act. Each
the decision regarding their OHIP eligibility may request Temporary Resident Permit has a case type or numerical
an appeal of their case by the Health Services Appeal designation on the permit that indicates the circum-
and Review Board. stances allowing the individual entry into Canada.
Individuals who hold a permit with a case type of 86, 87,
MOHLTC is the sole payer for OHIP insured physician, 88, 89, 90, 91, 92, 93, 94, 95 or 80 (if for adoption) are
hospital and hospital surgical-dental services. An eligible eligible for OHIP coverage. Individuals who hold a
Ontario resident may not obtain any benefits from another permit with a case type of 80 (except for adoption), 81,
insurance plan for the cost of any insured service that is 84, 85 and 96 are not eligible for OHIP coverage.
covered by OHIP (with the exception of during the OHIP
waiting period). Clergy, Foreign Workers and their Accompanying
Family Members: An eligible foreign clergy is a person
Persons who were previously ineligible for OHIP coverage who is sponsored by a religious organization or denomina-
but whose status and/or residency situation has changed tion if the member has finalized an agreement to minister
may be eligible upon application, subject to the require- to a religious congregation or group in Ontario for at least
ments of Regulation 552. six months, as long as the member is legally entitled to
stay in Canada.
MOHLTC provides health insurance coverage to a limited A foreign worker is eligible for OHIP if the individual has
number of specified categories of residents of Ontario, been issued a Work Permit or other document by IRCC
other than Canadian citizens and permanent residents that permits the person to work in Canada, and if the
or landed immigrants. person also has a formal agreement in place to work
full-time for an employer in Ontario. The work permit or
These residents are required to provide acceptable orig-
other document issued by IRCC, or a letter provided by
inal documentation to support their residence in Ontario
the employer, must set out the employer’s name, state
and their identity in the same manner as Canadian citizens
the person’s occupation with the employer, and state
and permanent resident or landed immigrant applicants.
that the person will be working for the employer for no
The individuals listed below who are residents in Ontario less than six consecutive months.
may be eligible for OHIP coverage in accordance with
A spouse and/or dependent (under 22 years of age; or
Regulation 552 of the Health Insurance Act. Individuals
22 years of age or older if dependent due to a mental or
are required to apply in person to ServiceOntario, which
physical disability) of an eligible foreign member of the
has the government-wide mandate for the delivery of
clergy or an eligible foreign worker is also eligible for
front-facing services to the residents of Ontario, including
OHIP coverage as long as the spouse or dependent is
the issuance of the Ontario Photo Health Card.
legally entitled to stay in Canada.
Applicants for Permanent Residence: These are persons
Live-in Caregivers: Eligible live-in caregivers are persons
who have submitted an application for Permanent Resident
who hold a valid Work Permit under the Live-in Caregiver
status to Immigration, Refugees and Citizenship Canada
Program (LCP) administered by the Government of
(IRCC), and IRCC has confirmed that the person meets
Canada. The Work Permit for LCP workers does not have
the eligibility requirements to apply for permanent resi-
to list the three specific employment conditions required
dence in Canada and that the application has not yet
for all other foreign workers.
been denied.
Applicants for Canadian Citizenship: These individuals
Protected Persons: These are persons who are deter-
are eligible for OHIP coverage if they have submitted an
mined to be Protected Persons under the terms of the
application for Canadian citizenship under section 5.1 of
federal Immigration and Refugee Protection Act. Members
the federal Citizenship Act, even if the application has
of this group are provided with immediate OHIP coverage.
not yet been approved, provided that IRCC has confirmed

CHAPTER 3 | ONTARIO
that the person meets the eligibility requirements to ap- province or territory where they are insured will typically
ply for citizenship under that section and the application be eligible for OHIP coverage after the last day of the
has not yet been denied. second full month following the date residency is estab-
lished, in other words, an interprovincial waiting period.
Children Born Out-of-Country: A child born to an OHIP-
eligible woman who was transferred from Ontario to 4.2 Coverage During Temporary Absences in Canada
receive insured health services that were pre-approved Ontario adheres to the terms of the Interprovincial
for payment by OHIP is eligible for immediate OHIP Agreement on Eligibility and Portability (EPA), As
coverage provided that the mother was pregnant at the per section 1.6 of Regulation 552, and in accordance
time of departure from Ontario. with the EPA, an insured person who leaves Ontario
temporarily to travel within Canada, without establishing
Seasonal Agricultural Farm Workers: are persons residency in another province or territory, may continue
who have a Work Permit issued under the Seasonal to be covered by OHIP for a period of up to 12 months.
Agricultural Worker Program administered by the
Government of Canada. Due to the special nature of An insured person who temporarily seeks or accepts
their employment, migrant farm workers do not have to employment in another province or territory may
meet any other residency requirement and are provided continue to be covered by OHIP for a period of up to
with immediate OHIP coverage. 12 months. If the individual plans to remain outside
Ontario beyond the 12 month maximum, he or she should
3.3 Premiums apply for coverage in the province or territory where that
No premiums are required to obtain OHIP coverage. person has been working or seeking work.
There is an Ontario Health Premium that is collected
through the provincial income tax system but it is not As per section 1.8 of Regulation 552, and in accordance
connected to OHIP registration or eligibility in any way. with the EPA, insured students who are temporarily
Responsibility for the administration of the Ontario Health absent from Ontario, but remain within Canada, may be
Premium lies with the Ontario Ministry of Finance. eligible for continuous health insurance coverage for the
duration of their full-time studies, provided they do not
establish permanent residency elsewhere during this
4.0 PORTABILITY period. To ensure that they maintain continuous OHIP
eligibility, a student should provide the Ministry of
4.1 Minimum Waiting Period Health and Long-Term Care (MOHLTC) with documen-
In accordance with section 5 of Regulation 552 under tation or information from their educational institution
the Health Insurance Act, individuals who move to confirming registration as a full-time student. Insured
Ontario are typically entitled to Ontario Health Insurance family members (spouses and dependents) of students
Plan (OHIP) coverage three months after establishing who are studying in another province or territory are also
residency in the province unless listed as an excep- eligible for continuous OHIP eligibility while accompany-
tion in sections 6, 6.1, 6.2, or 6.3 of Regulation 552, or ing students for the duration of their studies.
subsection 11(2.1) of the Health Insurance Act.
Also, In accordance with section 1.6 and 1.8 of Regulation
Assessment of whether or not an individual is subject to 552 of the Health Insurance Act, most insured residents
the waiting period occurs at the time of their application who want to travel, work or study outside Ontario, but
for OHIP coverage. Examples of those who are exempt within Canada, and maintain OHIP coverage, must have
from the three month waiting period include newborn resided in Ontario for at least 153 days in the last 12
babies, eligible military family members, and insured month period immediately prior to departure from Ontario.
residents from another province or territory who move
to Ontario and immediately become residents of an Payments for insured out-of-province services are
approved long-term care home in Ontario. prescribed under sections 28, 28.0.1, 28.0.2, and 29
of Regulation 552 of the Health Insurance Act. Insured
In accordance with Regulation 552 under the Health residents who are temporarily outside of Ontario can
Insurance Act and as provided for in the Interprovincial use their valid Ontario health cards to obtain insured
Agreement on Eligibility and Portability, persons who physician (except in Quebec) and hospital services
permanently move to Ontario from another Canadian generally at no direct cost.
70
CHAPTER 3 | ONTARIO
Ontario participates in Reciprocal Hospital Billing Reason OHIP Coverage

Agreements with all other provinces and territories for pay-
Study Duration of full-time academic studies
ment of insured in-patient and out-patient hospital services.
(unlimited)
Rates are set and approved annually by the Interprovincial
Health Insurance Agreements Coordinating Committee. Work Five-year terms (specific residency
Payment for in-patient services is at the hospital’s approved requirements must be met for 2 years
in-patient per diem rate. Payment for out-patient services between absences)
is at the standard approved out-patient rate. Charitable Five-year terms (specific residency
Worker requirements must be met for 2 years
Ontario is also party to the Physicians’ Reciprocal Billing between absences)
Agreements with all other provinces and territories, except
Vacation/ Two-year terms (specific residency
Quebec (which has not signed a reciprocal physician
Other requirements must be met for 5 years
agreement with any other province or territory). Ontario
between absences)
residents who may be required to pay for insured physi-
cian services in another province or territory can submit Certain family members may also qualify for continuous
their receipts to MOHLTC for payment at Ontario rates. OHIP coverage while accompanying the primary applicant
on an extended absence outside Canada.
Out-of-province (within Canada)
Out-of-province (but within Canada) genetic tests or Out-of-Country Coverage for Ontario Residents who
other laboratory tests performed outside of a publicly are Temporarily Absent
funded hospital require prior approval in accordance Payment of out-of-country services for Ontarians
with Section 28.0.2 of Regulation 552. In addition, who are temporarily absent from Canada, such as for
certain medical services that require prior approval travelling, are captured under Regulation 552 of the
in Ontario (as prescribed in the Schedule of Benefits Health Insurance Act.
for Physician Services for services including breast
reduction and panniculectomy) must be prior approved Out-of-country costs are for hospital and health
if the service is sought in another province or territory. facility services required to treat a condition that is acute
and unexpected, arose outside of Canada, and requires
4.3 Coverage During Temporary Absences immediate treatment. They are reimbursed at rates set
Outside Canada out in Regulation 552 under the Health Insurance Act:
Residents may be temporarily outside of Canada for
a total of 212 days in any 12 month period and still • a maximum $400 (CAD) for in-patient services for a
maintain OHIP coverage as long as their primary place higher level of care as described in the Regulations
of residence remains Ontario. and $200 (CAD) for any other level of care;
Extended Absences: Health insurance coverage for • a maximum $50 (CAD) for out-patient services (except
insured Ontario residents during extended absences dialysis); and
(longer than 212 days) outside Canada is governed by
Regulation 552 of the Health Insurance Act. • a maximum of $210 (CAD) for renal dialysis.
The MOHLTC requests that residents apply to MOHLTC During 2015–2016, out-of-country emergency, medically
to confirm this coverage before their departure and pro- necessary, out-of-country physician services were
vide documents explaining the reason for their absence. reimbursed at the Ontario rates set out in Regulation
552 under the Health Insurance Act or the amount billed,
In accordance with regulations and MOHLTC policy, whichever was less.
most applicants must also have been residents in Ontario
for at least 153 days in each of the two consecutive 12 4.4 Prior Approval Requirement
month periods before their expected date of departure. As set out in Regulation 552 under the Health Insurance
Act, written prior approval from MOHLTC is required for
The length of time that a person can receive continuous payment for non-emergency health services provided
Ontario health insurance coverage during an extended outside of Canada prior to the medical services being
absence outside Canada varies depending on the reason rendered.
for the absence as follows:

CHAPTER 3 | ONTARIO
The prior approval application which includes written charge or accept payment or other benefit for an insured
confirmation from the referring Ontario physician must service rendered to an insured person except as
establish that the services or tests are: permitted in the CFMA. The CFMA further prohibits any
person or entity from paying, conferring, charging or
• medically necessary; and accepting a payment or other benefit in exchange for
preferred access (queue jumping) for an insured service.
• performed at an out-of-country licensed hospital or
In addition, the CFMA prohibits physicians, practitioners
health facility (as defined in the Regulations); and
and hospitals from refusing to provide an insured
• not experimental or for the purposes of research or a service if an insured person chooses not to pay a “block
survey; and fee” for an uninsured service.
• generally accepted by the medical profession in Ontario The Ministry of Health and Long-Term Care (MOHLTC)
as appropriate for a person in the same medical circum- investigates all possible contraventions of the CFMA
stances as the insured person; and either that come to its attention. For situations in which it is
determined that extra-billing has occurred, the MOHLTC
• not performed in Ontario by an identical or equivalent ensures that the amount is repaid to the payee.
procedure; or
Health Card Validation (HCV) assists health care
• performed in Ontario but the insured person must providers with access to information requested for
travel outside of Canada to avoid delay that would claims payment. HCV allows the provider to determine
result in death or medically significant irreversible the point-in-time status of a patient’s Ontario health
tissue damage. number (and version code) indicating eligibility or
ineligibility for provincially funded health care services,
Except in an emergency, written prior approval of thereby reducing claim rejects. A health care provider
payment must be granted by the General Manager may subscribe for validation services if they have a valid
before any of the health services are rendered. and active billing number as assigned by the MOHLTC.
Requests for prior approval of funding require the en- If patients require access to insured services and do not
dorsement of a physician who is a specialist in the type have a valid health card in their possession, upon
of services for which prior approval has been requested. obtaining patient consent, the provider may obtain the
This requirement does not apply to emergency services necessary information by utilizing the accelerated health
and services that are within a general practitioner’s number release service provided by ServiceOntario’s
scope of practice. Health Number Look Up service which is offered 24
hours a day, 365 days per year to physicians or hospitals
There are also other specified requirements in section registered for this service.
28.4 of Regulation 552 depending on the nature of the
service for which funding is requested. Acute care priority services are designated, highly
specialized, hospital-based services that deal with
Funding requirements for non-emergency laboratory life-threatening conditions such as organ transplants,
tests performed outside Canada are described in section cancer surgery and treatments, and neuroservices. These
28.5 of Regulation 552 of the Health Insurance Act. services are often high-cost and are rapidly growing,
which has made access a concern. Generally, these ser-
5.0 ACCESSIBILITY vices are managed provincially, on a time-limited basis.
5.1 Access to Insured Health Services Acute care priority services include:
All insured hospital, physician, and designated practi- • selected cardiovascular services;
tioner services, are available to Ontario residents as set
• selected cancer services;
out in the Health Insurance Act and Regulations.
• chronic kidney disease services;
Access to insured services is protected under Part II of
the Commitment to the Future of Medicare Act (CFMA), • critical care services; and
“Health Services Accessibility.” The CFMA prohibits
extra-billing by ensuring that a person or entity cannot • organ and tissue donation and transplantation.
72
CHAPTER 3 | ONTARIO
Primary Health Care: During 2015-2016, consistent with There are a number of existing initiatives to improve
the government direction outlined in Patients First: access across Ontario, including but not limited to the
Action Plan for Healthcare 2015, Ontario continued to Northern and Rural Recruitment and Retention Initiative
align its new and existing primary health care delivery (NRRRI), the Northern Physician Retention Initiative (NPRI),
models to help improve and expand access to primary and the Northern Health Travel Grant (NHTG) Program.
health care physician services for all Ontarians. The
various primary health care physician compensation • Northern and Rural Recruitment and Retention
models encourage access to comprehensive primary Initiative (NRRRI): The NRRRI supports the recruit-
health care services for Ontario as a whole, as well as for ment and retention of physicians in rural and northern
targeted population groups and remote under- communities. The NRRRI provides financial recruit-
serviced communities. Following extensive facilitated ment incentives to physicians who establish a full-
province-wide consultation with Local Health Integration time practice in an eligible community. Community
Networks, providers, associations and the general eligibility for the NRRRI is based on a Rurality Index
public, Ontario introduced Bill 210, the proposed for Ontario score of 40 or more. Also eligible are the
Patients First Act, 2016 in June 2016. If passed, Bill 210 five Northern Ontario Census Urban Referral Centre
will improve access to health care services by giving census metropolitan areas (Thunder Bay, Sudbury,
patients and their families faster and better access to North Bay, Sault Ste. Marie and Timmins).
care and putting them at the centre of a truly integrated
• Northern Physician Retention Initiative (NPRI): The
health system. It would improve and integrate local
NPRI provides physicians who have completed a
planning and delivery of front-line primary care and in-
minimum of four years of continuous full-time practice
home community services to support easier access to
in Northern Ontario with a $7,000 retention incentive
care, better coordination and continuity of care.
paid at the end of each fiscal year in which they con-
Health Care Connect (HCC): HCC helps Ontarians tinue to practice full-time in Northern Ontario. NPRI
who are without a primary health care provider (family supports retention of physicians in Northern Ontario
doctor or nurse practitioner) to find one. Insured and encourages them to maintain active hospital priv-
persons without a primary health care provider who ileges. Northern Ontario is defined as the districts
register with HCC may be referred to a family doctor or of Algoma, Cochrane, Kenora, Manitoulin, Nipissing,
a nurse practitioner if there is an available provider who Parry Sound, Muskoka, Rainy River, Sudbury, Thunder
is accepting new patients in their community. Bay and Timiskaming.
During 2015–2016, MOHLTC continued to administer • Northern Health Travel Grant (NHTG) Program:
various initiatives in order to improve access to health care The NHTG Program helps defray travel-related costs
services across the province. Ontario’s physician supply for residents of Northern Ontario who must travel
has stabilized due to past medical school expansion and long distances to access insured medical specialist
ongoing evidence-informed planning, and the province services, or designated health care facility-based
is working to enhance the retention and distribution of procedures that are not locally available, within a
physicians through such measures as: radius of 100km. The NHTG Program also promotes
using specialist services located in Northern Ontario,
• supporting rural and remote clinical education oppor- which encourages more specialists to practice and
tunities for medical students; remain in the north.
• supporting the Northern Ontario School of Medicine; 5.2 Physician Compensation

Physicians are paid for the services they provide through
•
supporting training and assessment programs for a number of mechanisms. Some physician payments
International Medical Graduates and other qualified are provided through fee-for-service arrangements.
physicians who do not meet certain requirements for Remuneration is based on the Schedule of Benefits —
practice in Ontario; and Physician Services under the Health Insurance Act. Other
physician payment models include Primary Health Care
•
supporting the HealthForceOntario Marketing and
Models (such as blended capitation models), Alternate
Recruitment Agency to help recruit and retain health care
Payment Plans, and new funding arrangements for phy-
professionals in Ontario communities that need them.
sicians in Academic Health Science Centres.

CHAPTER 3 | ONTARIO
In 2015-2016, 97 per cent of General Practitioners re- •

Health System Funding Reform (HSFR) including
ceived fee-for-service payments from OHIP, but fewer Health Based Allocation Model (HBAM) and Quality
than 30 per cent of them were paid solely on a fee-for- Based Procedures (QBPs);
service basis. The majority (70 per cent) of primary care
physicians in Ontario received funding through one of • Non-HSFR base funding, such as Post-Construction
the primary health models: Comprehensive Care (CCM), Operating Plan (PCOP); and
Family Health Group (FHG), Family Health Network (FHN),
• Wait Times, Priority Programs and other non-HSFR
Family Health Organization (FHO), Community Health
base funding.
Centres (CHC), Rural and Northern Physician Group
Agreement (RNPGA), Group Health Centre (GHC), Blended On April 1, 2012, Ontario began the implementation of
Salary Model (BSM), and specialized agreements. the Health System Funding Reform (HSFR) Strategy
for funding hospitals. HSFR shifts health care funding
Family Health Teams (FHTs) are independent, non-profit
from a predominantly global budget system towards an
organizations that provide interdisciplinary team-based
activity-based funding model which ensures that
primary health care; they are staffed by providers such
patients get the right care, at the right place, at the right
as nurse practitioners, nurses, social workers and
time, and at the right price. HSFR offers an integrated
dieticians. Physician groups that can affiliate with
approach to health system funding and puts the patient
and participate in FHTs are funded by one of three
at the core through adopting a ‘funding follows the
compensation options: Blended Capitation (such as
patient’ principle. HSFR is a significant shift from the
FHN or FHO), Complement Based Models (RNPGA or
way Ontario hospitals were traditionally funded, which
other specialized agreements) and BSM (for community
was largely based on historically-derived global budgets,
sponsored FHTs). FHTs are located across Ontario, in
which were established in 1969.
both urban and rural settings, ranging in size, structure,
scope and governance. HSFR is comprised of two key components: HBAM and
QBP funding, which together comprised approximately
MOHLTC negotiates many elements of physician
51 per cent of hospital’s total funding in 2016–2017 (37
compensation with the Ontario Medical Association
per cent HBAM; 14 per cent QBP).
(OMA). The last Physician Services Agreement (PSA) ex-
pired on March 31, 2014 and the MOHLTC and the OMA Health-Based Allocation Model: Is an evidence-based,
commenced negotiations for a new PSA in January health-based funding formula. HBAM enables the gov-
2014. The MOHLTC and the OMA negotiated from January ernment to equitably allocate available funding at the
2014 to January 2015, but they were unsuccessful in organizational level to health service providers. HBAM
reaching a PSA. In the absence of a new PSA, the uses an algorithm to identify a health service provider’s
MOHLTC implemented a set of initiatives (Ten-Point future expected expense levels. Funding is then allocated
Plan for Saving and Improving Service) to change the amongst providers based on the share of their expected
funding for certain physician services and programs. expense calculation and available funding. A health sys-
tem provider’s expected expense is determined based
The MOHLTC subsequently engaged the OMA in
on past patient services delivered and efficiency, as well
confidential discussions from October 2015 to July
as population and health information, such as: age, gender,
2016, focused on working towards the next PSA. These
population growth rates, diagnosis and procedures.
discussions led to a tentative agreement on July 7, 2016
On August 14, 2016, the OMA held a ratification vote Quality-Based Procedures: QBPs are an integral part
and the PSA was rejected by the OMA membership. of HSFR as they align funding with quality improvement.
They target clusters of patients with clinically related
The MOHLTC continues to work with the OMA in hopes
diagnoses or treatments that have been identified by
of agreeing upon a new PSA.
an evidence-based framework as providing opportunity
5.3 Payments to Hospitals for process improvements, clinical redesign to improve
Ontario hospitals are funded through a mix of base fund- patient outcomes, enhanced patient experience and
ing, which is on-going funding, and one-time funding. potential cost savings. QBPs allow the health system to
The majority of funding provided to hospitals is through achieve better quality and system efficiencies. The price
base funding, which is comprised of: for most QBPs is currently based on the average price
of providing care, adjusted for patient acuity.
74
CHAPTER 3 | ONTARIO
Non-HSFR Base will continue to be used for activities

that cannot be modeled, including those that are unique
(such as forensic mental health), or where HSFR would
introduce significant funding instability (such as small
hospitals).
The Post-Construction Operating Plan (PCOP) Program

provides operational funding to support the service and
facility expansions associated with approved capital
projects. Ontario’s Wait Time Strategy provides targeted
funding to improve access to key health services by re-
ducing wait times. Provincial Program funding supports
programs such as certain specialized cardiac services
that are managed at a provincial rather than regional level.
Hospital Service Accountability Agreements (H-SAA):

When the Local Health Integration Networks (LHINs)
assumed responsibility for their local health care
systems they negotiated two year H-SAAs with their
respective hospitals and became the lead for the
Hospital Annual Planning Submissions, which inform
the H-SAAs. The LHINs have amended the 2008/09–
2009/10 H-SAA each year from 2010/11 to 2015/16
versus negotiating a new two year agreement. These
are referred to as Amending Agreements.
Public hospitals submit planning submissions to the

LHINs that are the result of broad consultations within
the organizations (all levels of staff, unions, physicians
and board), the community and region. Some of the
data submitted in the planning submissions are used to
populate schedules for service volumes and performance
targets that form the contractual basis for the H-SAA.
The H-SAA outlines the terms and conditions of the ser-

vices provided by the hospital, the funding it will receive,
along with the performance levels expected. There are
various performance indicators that are monitored,
managed and evaluated in the agreement.
6.0 RECOGNITION GIVEN TO

FEDERAL TRANSFERS
The Government of Ontario publicly acknowledged the
federal contributions provided through the Canada Health
Transfer in its Public Accounts of Ontario 2015-2016.

CHAPTER 3 | ONTARIO
REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number as of March 31st (#) 13,212,728 1
13,349,791 1
13,452,921 1
13,545,565 1
13,723,4651

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 147 2
146 2
145 2
145 2
1432

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of private for-profit facilities not available 4
not available4
not available4
not available4
not available4
Payments to private for-profit facilities for not available4 not available4 not available4 not available4 not available4

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA5

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total number of claims, out-patient (#) not available not available not available not available not available
Total payments, out-patients ($) not available not available not available not available not available
These estimates represent the number of Valid and Active Health Cards (have current eligibility and resident has incurred a claim in
1
the last 7 years).
2 Number represents all publicly funded hospitals excluding specialty psychiatric hospitals. Specialty psychiatric hospitals are excluded
in order to conform to Canada Health Act Annual Report requirements.
3 Amount represents funding for all public hospitals excluding specialty psychiatric hospitals. Fiscal Year 2015–2016 is based on Public
Accounts.
Data are not collected in a single system in MOHLTC. Further, the MOHLTC is unable to categorize providers/facilities as “for-profit”
4
as MOHLTC does not have financial statements detailing service providers’ disbursement of revenues from the Ministry.
Indicators 10 and 11 include both in-patient and out-patient.
5
76
CHAPTER 3 | ONTARIO

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
physicians (#)
physicians (#)
physicians (#) 6
Total payments for services 11,008,532,900 11,228,719,988 11,379,311,227 11,823,825,604 11,918,882,881
through all payment methods ($) 7

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 25,252,852 26,017,930 30,248,528 31,360,835 29,524,980

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 7,922,281 6,537,845 5,844,999 6,473,814 6,518,994

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 13,532,519 12,525,404 12,713,974 12,040,331 12,442,618
6 Ontario has no non-participating physicians, only opted-out physicians who are reported under item #15.
7 Total payments includes payments made to Ontario physicians through Fee-for-Service, Primary Care, Alternate Payment Programs,
Academic Health Science Centres, the Hospital On Call Program and Health Care Connect. Services and payments related to Other
Practitioner Programs, Out-of-Country/ Out-of-Province Programs, Nurse Practitioners, Interprofessional Shared Care, NP Led Clinics,
Family Health Teams and Community Labs are excluded. Fiscal Years 2011–2012, 2012–2013, 2013–2014, 2014–2015, and 2015-2016
agree with Public Accounts.

CHAPTER 3 | MANITOBA
MA NITO BA
Manitoba Health, Seniors and Active Living 1.2 Reporting Relationship
(MHSAL) provides leadership and support to Section 6 of the Health Services Insurance Act requires
the Minister to have audited financial statements of the
protect, promote and preserve the health of all
MHSIP showing separately the expenditures for hospital
Manitobans. MHSAL continues efforts to improve services, medical services and other health services. The
access, service delivery, capacity, innovation, Minister is required to prepare an annual report, which
sustainability and improve the health status of must include the audited financial statements, and to
Manitobans while reducing health disparities. table the report before the Legislative Assembly within
15 days of receiving it, if the Assembly is in session. If the
The roles and responsibilities of the department
Assembly is not in session, the report must be tabled
include policy, program and standards develop- within 15 days of the beginning of the next session.
ment; fiscal and program accountability; and
evaluation. In addition, specific direct services 1.3 Audit of Accounts
Section 7 of the Health Services Insurance Act requires
continue to be provided through Selkirk Mental
that the Office of the Auditor General of Manitoba (or
Health Centre, Cadham Provincial Laboratory, another auditor designated by the Office of the Auditor
public health inspections, and provincial nursing General of Manitoba) audit the accounts of the MHSIP
stations. 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 2015–2016 fiscal
year and is contained in the Manitoba Health Annual
Report, 2015–2016. It is available at www.gov.mb.ca/
1.0 PUBLIC ADMINISTRATION health/ann/index.html.
1.1 Health Care Insurance Plan and Public Authority
The Manitoba Health Services Insurance Plan (MHSIP)
is administered by MHSAL under the Health Services
Insurance Act, R.S.M. 1987, c. H35. 2.1 Insured Hospital Services
Sections 46 and 47 of the Health Services Insurance
The MHSIP is administered under this Act and insures
Act, as well as the Hospital Services Insurance and
the costs of hospital, personal care, and medical and
Administration Regulation (M.R. 48/93), provide for
other health services referred to in acts of the Legislature
insured hospital services.
or related Regulations.
As of March 31, 2016, there were 96 facilities providing
The Minister of Health is responsible for administering
insured hospital services to both in- and out-patients.
and operating the MHSIP. The Minister may also enter into
Hospitals are designated by the Hospitals Designation
contracts and agreements with any person or group that
Regulation (M.R. 47/93) under the Act.
he or she considers necessary for the purposes of the Act.
Services specified by the Regulation as insured in-patient
The Minister may also make grants to any person or
and out-patient hospital services include: accommodation
group for the purposes of the Act on such terms and con-
and meals at the standard ward level; necessary nursing
ditions that are considered advisable. Also, the Minister
services; laboratory, radiological and other diagnostic
may, in writing, delegate to any person any power,
procedures; drugs, biologics and related preparations;
authority, duty or function conferred or imposed upon
routine medical and surgical supplies; use of operating
the Minister under the Act or under the Regulations.
room, case room and anaesthetic facilities; and use of
There were no legislative amendments to the Act or the radiotherapy, physiotherapy, occupational and speech
Regulations in the 2015-2016 fiscal year that affected therapy facilities where available.
the public administration of the MHSIP.
78
The Regulation states that hospital in-patient services During fiscal year 2015-2016, a number of new insured
include routine medical and surgical supplies, thereby services were added to a revised fee schedule. The
ensuring reasonable access for all residents. The regional Physician’s Manual can be viewed online at: www.gov.
health authorities and MHSAL monitor compliance. mb.ca/health/manual/index.html.
Manitoba residents maintain high expectations for quality The process for a medical service to be added to the list
health care and insist that the best available medical of those covered by MHSAL is that physicians must put
knowledge and service be applied to their personal health forward a proposal to their specific section of
situations. Doctors Manitoba. Doctors Manitoba will negotiate the
item, including the fee, with MHSAL. MHSAL may also
2.2 Insured Physician Services initiate this process.
The enabling legislation that provides for insured
physician services is the Medical Services Insurance 2.3 Insured Surgical-Dental Services
Regulation (M.R. 49/93) made under the Health Services Insured surgical and dental services are listed in the
Insurance Act. Hospital Services Insurance and Administration Regulation
(M.R. 48/93) under the Health Services Insurance Act.
Physicians providing insured services in Manitoba must Surgical services are insured when performed by a cer-
be lawfully entitled to practice medicine in Manitoba, and tified oral and maxillofacial surgeon or a licensed dentist
be registered and licensed under the Medical Act. As of in a hospital, when hospitalization is required for the
April 30, 2015, there were 2748 physicians registered in proper performance of the procedure. This Regulation
Manitoba, with 2533 participating in the MHSIP. also provides benefits relating to the cost of insured
orthodontic services in cases of cleft lip and/or palate for
A physician, by giving notice to the Minister in writing,
persons registered under the program by their 18th
may elect to collect the fees other than from the Minister
birthday, when provided by a registered orthodontist.
for medical services rendered to insured persons, in
accordance with section 91 of the Act and section 5 of Providers of dental services may elect to collect their fees
the Medical Services Insurance Regulation. The election directly from the patient in the same manner as
to opt out of the health care insurance plan takes effect physicians and may not charge to, or collect from, an
on the first day of the month following a 90-day period insured person a fee in excess of the benefits payable
from the date the Minister receives the notice. under the Act or Regulations. No providers of dental
services had opted out in 2015-2016
Before rendering a medical service to an insured person,
physicians must give the patient reasonable notice that In order for a dental service to be added to the list of
they propose to collect any fee for the medical service insured services, a dentist must put forward a proposal
from them or any other person except the Minister. The to the Manitoba Dental Association (MDA). The MDA
physician is responsible for submitting a claim to the negotiates the item and fee with MHSAL.
Minister on the patient’s behalf and cannot collect fees
in excess of the benefits payable for the service under 2.4 Uninsured Hospital, Physician and
the Act or Regulations. No physicians opted out of the Surgical-Dental Services
medical plan in 2015-2016. The Excluded Services Regulation (M.R. 46/93) made
under the Health Services Insurance Act sets out those
The range of physician services insured by MHSAL is listed services that are not insured. These include: examina-
in the Payment for Insured Medical Services Regulation tions and reports for reasons of employment, insurance,
(M.R. 95/96). Coverage is provided for all medically re- attendance at university or camp, or performed at the
quired personal health care services that are not exclud- request of third parties; group immunization or other
ed under the Excluded Services Regulation (M.R. 46/93) group services except where authorized by MHSAL;
of the Act, rendered to an insured person by a physician. services provided by a physician, dentist, chiropractor
or optometrist to him or herself or any dependents;

preparation of records, reports, certificates, commu- Manitoba for up to two years while still remaining resi-
nications and testimony in court; mileage or travelling dents of Manitoba. Students are deemed to be Manitoba
time; services provided by psychologists, chiropodists residents while in full-time attendance at an accredited
and other practitioners not provided for in the legislation; educational institution. Section 8(1) extends residency
in vitro fertilization; tattoo removal; contact lens fitting; to individuals who are legally entitled to work in Manitoba
reversal of sterilization procedures; and psychoanalysis. and have a work permit of 12 months or more and to
individuals who hold study permits of six months or
The Hospital Services Insurance and Administration more under the Immigration and Refugee Protection Act
Regulation states that hospital in-patient services include (Canada). Additionally, section 8.1.1 of the Residency and
routine medical and surgical supplies, thereby ensuring Registration Regulation extends deemed residency to
reasonable access for all residents. The regional health temporary foreign workers (and their dependents) in the
authorities and MHSAL monitor compliance. province to provide agricultural services on the basis of a
work permit, regardless of the duration of their work permit.
All Manitoba residents have equitable access to services.
Third parties such as private insurers or the Workers The Residency and Registration Regulation, section 6,
Compensation Board do not receive priority access to defines Manitoba’s waiting period as follows:
services through additional payment. Manitoba has no
formalized process to monitor compliance; however, “A resident who was a resident of another Canadian
feedback from physicians, hospital administrators, medical province or territory immediately before his or her arrival
professionals and staff allows regional health authorities in Manitoba is not entitled to benefits until the first day
and MHSAL to monitor usage and service concerns. of the third month following the month of arrival.”
To de-insure services covered by MHSAL, the Ministry Section 6 of the Residency and Registration Regulation
prepares a submission for approval by Cabinet. The need stipulates that there is no waiting period for dependents
for public consultation is determined on an individual of members of the Canadian Armed Forces.
basis depending on the subject.
There are currently no other waiting periods in Manitoba.
No services were removed from the list of those insured
by Manitoba Health in 2015-2016. The Manitoba Health Services Insurance Plan (MHSIP)
excludes residents covered under any federal plan,
including the following federal statutes: Aeronautics
3.0 UNIVERSALITY Act; Civilian War-related Benefits Act; Government
Employees Compensation Act; Merchant Seaman
3.1 Eligibility Compensation Act; National Defence Act; Pension Act;
The Health Services Insurance Act defines the eligibility Veteran’s Rehabilitation Act; federal inmates or those
of Manitoba residents for coverage under the provincial covered under legislation of any other jurisdiction
health care insurance plan. (Excluded Services Regulations subsection 2(2)). These
residents become eligible for health services insurance
Section 2(1) of the Act states that a resident is a person coverage upon discharge from the Canadian Forces, or
who is legally entitled to be in Canada, makes his or her in the case of an inmate of a penitentiary, upon discharge
home in Manitoba, is physically present in Manitoba for if the inmate has no resident dependents. Upon change
at least six months in a calendar year, and includes any of status, these persons have one month to register
other person classified as a resident in the Regulations, with MHSAL (Residency and Registration Regulation
but does not include a person who holds a temporary (M.R. 54/93, subsection 2(3)).
resident permit under the Immigration and Refugee
Protection Act (Canada), unless the Minister determines RCMP members are insured persons in Manitoba and
otherwise, or is a visitor, transient or tourist. are eligible for benefits under the MHSIP.
The Residency and Registration Regulation (M.R. 54/93) The process of issuing health insurance cards requires
extends the definition of residency. The extensions are that individuals inform and provide documentation to
found in sections 7(1) and 8(1). Section 7(1) allows mis- MHSAL that they are legally entitled to be in Canada, and
sionaries, individuals with out-of-country employment that they intend to be physically present in Manitoba for
and individuals undertaking sabbatical leave to be outside six months in a calendar year. They must also provide a
80
primary residence address in Manitoba. Upon receiving Students are considered residents and will continue
this information, MHSAL will provide a registration card to receive health coverage for the duration of their full-
for the individual and all qualifying dependents. time enrolment at any accredited educational institution.
The additional requirement is that they intend to return
Manitoba has two health-related numbers. The registra- and reside in Manitoba after completing their studies.
tion number is a six-digit number assigned to an individual Manitoba has formal agreements with all Canadian
18 years of age or older who is not classified as a provinces and territories for the reciprocal billing of
dependent. This number is used by MHSAL to pay for all insured hospital services.
medical service claims for that individual and all
designated dependents. A nine-digit Personal Health In-patient costs are paid at standard rates approved by
Identification Number (PHIN) is used for payment of all the host province or territory. Payments for in-patient,
hospital services and for the provincial drug program. high-cost procedures and out-patient services are based
on national rates agreed to by provincial and territorial
As of March 31, 2016, there were 1,320,343 residents reg- health plans. These include all medically necessary
istered with the Manitoba Health Services Insurance Plan. services as well as costs for emergency care.
There is no provision for a resident to opt out of the MHSIP. 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.
The Residency and Registration Regulation (M.R. 54/93,
Claims for physician medical services received in
sub-section 8(1)) requires that temporary workers pos-
Quebec are submitted by the patient or physician to
sess a work permit issued by Immigration, Refugees and
MHSAL for payment at host province rates.
Citizenship Canada for at least 12 consecutive months,
be physically present in Manitoba for six months in a 4.3 Coverage During Temporary
calendar year, and be legally entitled to be in Canada Absences Outside Canada
before receiving MHSIP coverage. The Residency and Registration Regulation (M.R. 54/93,
sub-section 7(1)) defines the rules for portability of health
Section 8.1(a.1) of the Residency and Registration
insurance during temporary absences from Canada.
Regulation extends deemed residency to foreign students
(and their dependents) holding a valid study permit with Section 7(1)(g) of the Residency and Registration
a duration of 12 months or more. Regulation extends the period during which a person
may be temporarily absent from Manitoba for the
Section 8.1.1 of the Residency and Registration Regulation
purpose of residing outside of Canada from six months
extends deemed residency to temporary foreign workers
to a maximum of seven months in a 12-month period.
(and their dependents) in the province to provide agricul-
tural services on the basis of a work permit, regardless Residents on full-time employment contracts outside
of the duration of their work permit. Canada will receive health services insurance coverage
for up to 24 consecutive months. Individuals must return
4.0 PORTABILITY and reside in Manitoba after completing their employment
terms. Clergy serving as humanitarian aid workers or
4.1 Minimum Waiting Period missionaries on behalf of a religious organization approved
The Residency and Registration Regulation (M.R. 54/93, as a registered charity under the Income Tax Act (Canada)
section 6) identifies the waiting period for insured will be covered by MHSAL for up to 24 consecutive
persons from another province or territory. A resident months. Students are considered residents and will con-
who lived in another Canadian province or territory tinue to receive health coverage for the duration of their
immediately before arriving in Manitoba is entitled to full-time enrollment at an accredited educational institu-
benefits on the first day of the third month following the tion. The additional requirement is that they intend to
month of arrival. return and reside in Manitoba after completing their
4.2 Coverage During Temporary Absences in Canada studies. Residents on sabbatical or educational leave
The Residency and Registration Regulation (M.R. 54/93 from employment will be covered by MHSAL for up to 24
section 7(1)) defines the rules for portability of health consecutive months. These individuals also must return
insurance during temporary absences in Canada. and reside in Manitoba after completing their leave.

Manitoba residents receiving coverage under the MHSAL remains committed to the principles of Medicare
provincial health insurance plan who receive medical and improving the health status of all Manitobans. In
and hospital services outside of Canada are eligible 2015-2016 Manitoba continued to support these commit-
to be reimbursed at the rates set out in the Medical ments through such activities as:
Services Insurance Regulation and the Hospital Services
Insurance and Administration Regulation. Emergency • Partnered with regional health authorities and primary
doctors’ services outside of Canada are reimbursed at care physicians to match 95 per cent of all registrants
a rate equal to what a Manitoba doctor would receive without a primary care provider (48,081 people) since
for a similar service. Emergency hospital care is paid on the Family Doctor Finder program began in July 2013.
an average daily rate established by Manitoba Health, Overall satisfaction with program registration experience
Seniors and Active Living. was 91.5 per cent.
4.4 Prior Approval Requirement •

In collaboration with regional health authorities,
Prior approval is not required for procedures that are CancerCare Manitoba, and Diagnostic Services of
covered under the interprovincial reciprocal agreements Manitoba, worked towards reducing the cancer patient
with other provinces. Prior approval by MHSAL is journey from suspicion to treatment to two months or
required for high cost items or procedures that are not less for key selected cancer types.
included in the reciprocal agreements.
•
Facilitated implementation of a mobile clinic in
In order to be eligible for reimbursement, all non- Interlake-Eastern RHA, bringing the total up to three
emergency hospital and medical care provided outside in the province. These fully functional primary care
Canada requires prior approval from MHSAL. Manitobans clinics, staffed by nurse practitioners and primary
requiring medically necessary medical and/or hospital care nurses have improved access to primary care for
services unavailable in Manitoba or elsewhere in Canada rural Manitobans.
may be eligible for reimbursement of costs incurred
• Facilitated opening of three QuickCare Clinics in the
outside of Canada, pursuant to the Medical Services
WRHA (West Winnipeg, Seven Oaks and Southdale),
Insurance Regulation, by providing MHSAL with a rec-
bringing the total up to eight fully operational clinics.
ommendation from a specialist stating that the patient
Over 180,000 patients received access to episodic
requires a specific, medically necessary service.
primary care since the clinics opened. Survey results
of the clinics show a high degree of satisfaction from
patients and staff.
5.0 ACCESSIBILITY
• Providing funding to increase the number of medical
5.1 Access to Insured Health Services
and nursing professionals registered to practice in
MHSAL ensures that medical services are equitable and
Manitoba as follows:
reasonably available to all Manitobans. Effective January
1, 1999, the Surgical Facilities Regulation (M.R. 222/98) •
Specialist physicians increased by 49 (from
under the Health Services Insurance Act came into 1,345 to 1,394).
force to prevent private surgical facilities from charging
additional fees for insured medical services. •
General practitioners increased by 17 (from
1,337 to 1,354).
The Health Services Insurance Act, the Private Hospitals
Act and the Hospitals Act include definitions and other • Registered Nurses increased by 37 (from 13,510
provisions to ensure: to 13,547).
•
that no charges can be made to individuals who • Nurse Practitioners increased by 23 (from 149
receive insured surgical services, or to anyone else on to 172).
that person’s behalf; and
• Registered Psychiatric Nurses increased by 34
•
that a surgical facility cannot perform procedures (from 983 to 1,017).
requiring overnight stays and thereby function as a
private hospital. • Licensed Practical Nurses increased by 52 (from
3,303 to 3,355).
82
•
Oversaw the provincial implementation of digital and diabetes). Other efforts to support efficiency
mammography, which has resulted in more rapid include Advanced Access training and standards to
screening and diagnosis of breast cancer. enable primary care clinics and regional community
programs to measure access and work towards patient
• Worked with regional health authorities in Manitoba and access to a primary care provider within 24-48 hours.
Nunavut to implement a new Provincial Bed Utilization The implementation and increasing use of electronic
Committee to address patient flow issues and prioritize medical records in 80 per cent of primary care settings
admissions to Selkirk Mental Health Centre. also supports primary care continuous quality improve-
ment reporting for primary care services across Manitoba.
• Expanded, streamlined and increased efficiencies of
the Electronic Medical Record (EMR) Repository, with MHSAL continues to explore means to improve and
over 150 (and growing) primary care clinics regularly sustain access to acute care and emergency depart-
submitting EMR data. ment services throughout Manitoba within its fiscal
means. Efforts have been focused on improving the
• Improved access and quality of primary health care,
efficiency of services provided, enabling more services
including development of Quick Care clinics, primary
to be provided to Manitobans within existing funding.
care mobile clinics, the Advanced Access program
and Primary Care Networks. The Cancer Patient Journey initiative was established
in 2011 to streamline cancer services and dramatically
MHSAL continues to not only invest in improving clients’
reduce the wait time for patients between the time
access to primary care services across the province, but
cancer is suspected and the start of effective treatment
is also addressing continuity of care and ensuring a more
to two months or less.
comprehensive basket of services are provided. For
example, to achieve Manitoba’s commitment that all In November 2012 the province released an updated
Manitobans who wish to will have access to a family framework “Manitoba’s Cancer Strategy 2012–2017” for
physician, investments continue to be made in initiatives cancer control that will guide actions to build on the
such as Primary Care Networks and inter-professional major successes delivered under the 2007 provincial
teams, with 11 of these virtual teams now operational cancer strategic framework. The document, created
across the Province. In addition, Manitoba opened two with input from partners, stakeholders and cancer
more Quick Care Clinics for a total of eight and oper- patients themselves, outlines an integrated and
ated three mobile clinics, one in the Prairie-Mountain cohesive approach to cancer that involves prevention,
Regional Health Authority (RHA), Southern Health-Santé screening, diagnosis, research, treatment, palliative
Sud RHA and Interlake-Eastern RHA. A new primary care and survivorship.
care capacity planning process has been initiated to
better match supply of providers and demand for Manitoba continues to experience growth in the num-
services in order to better address the long standing ber of active practicing nurses. There were 18,091 active
needs of certain rural and remote communities. practicing nurses in Manitoba in 2015. This represents a
net gain of 146 nurses over 2014 (17,945).
Since 2013, the redeveloped Family Doctor Finder
program has enabled Manitobans to call or e-mail to be A renewed Collective Agreement was reached with the
registered and connected with a primary care provider. Manitoba Nurses’ Union (MNU) on April 9, 2014 and is in
This includes Regional Primary Care Connectors, who effect for four years, from April 1, 2013 to March 31, 2017.
work with regional primary care providers to find capac- The Agreement provides for wage increases of 10.1 per
ity in their practices to see new patients. To date, over cent over four years, which breaks down as follows: 2
48,000 Manitobans without a provider have found one per cent retroactively for 2013; 2 per cent in 2014 plus 1.1
through the program and 57–68 per cent of people were per cent market adjustment; 2 per cent in 2015; and 2
matched within five days of making the request. per cent in 2016 plus a 1 per cent market adjustment. As
part of the new Agreement, the parties made a number
Investment also continued in existing initiatives that of post-bargaining commitments, including the commit-
enhance capacity, quality and efficiency in primary care, ment to identify, develop and implement system deliv-
such as the Physician Integrated Network quality ery changes intended to improve the effectiveness and
indicators and, TeleCARE Manitoba (a chronic disease efficiency of health care service delivery in Manitoba.
self-management resource for congestive heart failure

The Nurses Recruitment and Retention Fund, established 5.2 Physician Compensation
in 1999, to assist regional health authorities to meet Manitoba continues to employ the following methods
nursing supply demands in terms of both recruitment of payment for physicians: fee-for-service, contract,
and retention in Manitoba has continued to provide blended and sessional. The Health Services Insurance
financial assistance in order to assist eligible nurses of Act governs remuneration to physicians for insured
all categories to offset the cost of re-entering the profes- services. There were no amendments to The Health
sion and relocate to work in Manitoba, and has provided Services Insurance Act related to physician compensation
funding to encourage nurses to work in rural and northern during the 2015-2016 fiscal year.
regions and other areas of need in order to enhance the
delivery of health care across the province. Fee-for-service remains the primary method of payment
for physician services. Alternate payment arrangements
In addition to ensuring a sufficient nursing workforce constitute a significant portion of the total compensation
supply, continued targeted efforts will be undertaken to physicians in Manitoba. Alternate-funded physicians
in order to ensure that nursing resources are optimized are those who receive non fee-for-service compensation,
and all nurses are provided opportunities to practice to including through a salary (employment relationship)
their full scope. or those who work on an independent contract basis.
Manitoba also uses blended payment methods where
Ongoing implementation of the overall healthcare trans- appropriate. As well, physicians may receive sessional
formation, whereby more services may be provided in payments for providing medical services on a time
the community, in primary care settings continues at based arrangement, as well as stipends for on-call and
pace with additional targeted efforts intended to be other responsibilities.
undertaken over the next few years to address both the
increasing age of this workforce, in terms of retire- MHSAL represents Manitoba in negotiations with physi-
ments, as well as the advancing age of the population in cians. The physicians are typically represented by Doctors
terms of the need for long term care services. Manitoba with some exceptions, such as oncologists
engaged by CancerCare Manitoba.
The Province has been supporting the expansion of
the Physician Assistant (PA) role in Manitoba. PAs are Doctors Manitoba and Manitoba reached a 4-year agree-
highly skilled health care professionals who practice ment on February 12, 2015 to renew the physician Master
medicine under the supervision of licensed physi- Agreement. The new physician Master Agreement took
cians. PAs are regulated by the College of Physicians & effect on April 1, 2015 and will expire on March 31, 2019.
Surgeons of Manitoba (CPSM) and must be registered
with the CPSM in order to practice in Manitoba. The The Manitoba Physician’s Manual lists all of the fee tariff
CPSM determines a PA’s specific scope of practice by descriptions, rates, rules of application and the dispute
approving their practice description, which is signed by resolution process in relation to fee-for-service payments
their supervising physician. to physicians. This document is the Schedule of Benefits
payable to physicians on behalf of insured persons in
Since Manitoba established its PA Regulation in 1999 Manitoba pursuant to the Medical Services Insurance
the role of the PA has grown from positions within acute Regulation under The Health Services Insurance Act.
surgical units (general, orthopedic and cardiac) to having
PAs providing clinical support in areas of mental health, All fee-for-service claims must be submitted electronically.
internal medicine, oncology and primary care. PAs The submission of paper claims is permitted on a limited
working in primary care in Manitoba have ranged from basis and only with the prior approval of MHSAL. Fee-
‘solo’ practices in rural Manitoba, supervised and for-service claims must be received within six months of
supported by physicians in a nearby community, to the date upon which the physician rendered the service.
working in both regional health authority run primary
During the 2015-2016 fiscal year, MHSAL implemented
care clinics and community-based fee-for-service clinics.
a new claims processing system to replace the legacy
The demand for PAs continues to grow as the
system which has been in use for over 40 years.
profession has shown great adaptability to address
access and service challenges throughout Manitoba’s 5.3 Payments to Hospitals
health system. As of September 12, 2016, there were Division 3.1 of Part 4 of the Regional Health Authorities
84 PAs registered with the CPSM. Act sets out the requirements for operating agreements
84
between regional health authorities and the operators of No legislative amendments to the Act or the Regulations
hospitals and personal care homes, defined as “health in 2015-2016 had an effect on payments to hospitals.
corporations” under the Act.
Pursuant to the provisions of division 3.1, regional health 6.0 RECOGNITION GIVEN TO
authorities are prohibited from providing funding to a
health corporation for operational purposes unless the FEDERAL TRANSFERS
parties have entered into a written agreement for this Manitoba regularly recognizes the federal role regarding
purpose that: enables the health services to be provided the contributions provided under the Canada Health
by the health corporation; enables the funding to be Transfer (CHT) in public documents. Federal transfers are
provided by the regional health authority for the health identified in the Estimates of Expenditures and Revenue
services; sets out the terms of the agreement; and (Manitoba Budget) document and in the Public Accounts
includes a dispute resolution process and remedies for of Manitoba. Both documents are published annually by
breaches. If the parties cannot reach an agreement, the the Manitoba government.
Act enables them to request that the Minister of Health
appoint a mediator to help them resolve outstanding
issues. If the mediation is unsuccessful, the Minister is
empowered to resolve the matter or matters in dispute.
The Minister’s resolution is binding on the parties.
There are three regional health authorities which have

hospitals operated by health corporations in their health
regions. The regional health authorities have required
agreements with health corporations that enable the
regional health authority to determine funding based on
objective evidence, best practices and criteria that are
commonly applied to comparable facilities. In all other
regions, the hospitals are operated by the Regional
Health Authorities Act. Section 23 of the Act requires
that regional health authorities allocate their resources
in accordance with the approved regional health plan.
The allocation of resources by regional health authorities

for providing hospital services is approved by MHSAL
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
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 (MHSIP) for insured hospital
services are to be paid to the regional health authorities.
In relation to those hospitals that are not owned and
operated by a regional health authority, the regional
health authority is required to pay each hospital in accor-
dance with any agreement reached between the regional
health authority and the hospital operator.

REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number as of March 31st (#) 1,265,059 1,271,388 1,289,268 1,317,861 1,320,3431

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 96 96 96 96 96
Payments for insured health services ($) not available not available not available not available not available

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Payments to private for-profit facilities for 2,005,150 1,928,985 2,040,914 02 02

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Population as of June 1st, 2015.

1
2 Beginning in 2014-2015, HSAL no longer has arrangements with private for-profit facilities. These facilities are accessible through Regional
Health Authorities. This is reflected retrospectively in a revised figure for 2014-2015.
86

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
physicians (#)
physicians (#)
Number of non-participating not applicable not applicable not applicable not applicable not applicable
physicians (#)
Total payments for services 927,916,000 988,164,000 1,082,193,000 1,134,521,000 1,204,757,000

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 10,989,977 11,127,080 11,137,758 11,963,709 12,545,113

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 703,353 1,148,432 888,084 1,048,275 1,269,879

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 1,468,524 1,231,972 1,493,071 2,083,453 1,531,281

CHAPTER 3 | SASKATCHEWAN
SAS KAT CH E WAN

Saskatchewan’s health system employs more than • pay part of, or the whole of, the cost of providing
40,000 people who provide a broad range of ser- health services for any persons or classes of person
who may be designated by the Lieutenant Governor-
vices. Twelve regional health authorities deliver
in-Council;
services in collaboration with the Saskatchewan
Cancer Agency, eHealth Saskatchewan, 3S • make grants or loans, or provide subsidies to regional
Health (Shared Services Saskatchewan), and the health authorities, health care organizations or munic-
ipalities for providing and operating health services or
Athabasca Health Authority. Affiliated health
public health services;
care organizations, and a wide variety of health
professionals in both the publicly funded health • pay part of, or the whole of, the cost of providing
care system and in private practice, are also health services in any health region or part of a health
region in which those services are considered by the
closely connected with health service delivery.
Minister to be required;
There are 28 self-regulated health professions in
the province, which are overseen by 26 regulatory • make grants or provide subsidies to any health agency
that the Minister considers necessary; and
bodies. The Ministry is responsible for governance
training and strategic oversight of the Boards •
make grants or provide subsidies to stimulate and
of Directors of RHAs and the Saskatchewan develop public health research, and to conduct
Cancer Agency. Boards, management, and health surveys and studies in the area of public health.
professionals at all levels are encouraged to play Sections 8 and 9 of the Saskatchewan Medical Care
leadership roles in the health system. Insurance Act provide the authority for the Minister of
Health to establish and administer a plan of medical care
The Ministry also supports the efforts of health insurance for residents. The Regional Health Services
regions, the Saskatchewan Cancer Agency, and Act, implemented in 2002, provides the authority to
other stakeholders to recruit and retain health establish 12 regional health authorities.
care providers, including nurses and physicians. Sections 3 and 9 of the Cancer Agency Act provide for
Partnerships with local, regional, provincial, establishing a Saskatchewan Cancer Agency and for
national and international organizations are the Agency to coordinate a program for diagnosing,
preventing and treating cancer.
encouraged, to help provide all Saskatchewan res-
idents with access to quality health care services. The mandates of the Ministry of Health, regional health
authorities and the Saskatchewan Cancer Agency are
More information about Ministry programs and outlined in the Health Administration Act, the Regional
services is available at www.saskatchewan.ca. Health Services Act and the Cancer Agency Act.

The Ministry of Health is directly accountable, and regu-
1.0 PUBLIC ADMINISTRATION larly reports, to the Minister of Health on the funding, and
administering the funds, for insured physician, surgical-
1.1 Health Care Insurance Plan and Public Authority dental and hospital services.
The provincial government is responsible for funding
and ensuring the provision of insured hospital, physician Section 36 of the Saskatchewan Medical Care Insurance
and surgical-dental services in Saskatchewan. Section Act requires that the Minister of Health submit an annual
6.1 of the Health Administration Act authorizes that the report concerning the medical care insurance plan to the
Minister of Health may: Legislative Assembly.
88
The Regional Health Services Act requires that each regional improve the information provided to the Legislative
health authority shall submit to the Minister of Health: Assembly. They are available on the Provincial Auditor’s
website at: http://www.auditor.sk.ca.
• a report on the activities of the regional health authority;
and
• a detailed, audited set of financial statements.
Pursuant to legislation, these reports and corresponding Section 8 of the Regional Health Services Act gives the
statements are then provided by the Minister to the Minister the authority to provide funding to a regional
Legislative Assembly. health authority or a health care organization for the
purpose of the Act.
Section 54 of the Regional Health Services Act requires
that regional health authorities and the Cancer Agency Section 10 of the Act permits the Minister to designate
submit to the Minister any reports that the Minister may facilities including hospitals, special care homes and
request from time to time. Regional health authorities health centres. Section 11 allows the Minister to pre-
and the Cancer Agency are required to submit various scribe standards for delivering services in those facilities
financial documents and a health service plan to the by regional health authorities and health care organiza-
Saskatchewan Ministry of Health. tions that have entered into service agreements with a
regional health authority.
The Provincial Auditor conducts an annual audit of gov- The Act sets out the accountability requirements for
ernment ministries and agencies, including the Ministry regional health authorities and health care organizations.
of Health. It includes an audit of Ministry payments in- These requirements include submitting annual financial
cluding but not limited to regional health authorities, the and health service plans for ministerial approval (section
Saskatchewan Cancer Agency, and physicians and dental 51), establishing community advisory networks (section
surgeons for insured physician and surgical-dental services. 28), and reporting critical incidents (section 58). The
Minister also has the authority to establish a provincial
Section 57 of the Regional Health Services Act requires surgical registry to help manage surgical wait times
that an independent auditor, who possesses the pre- (section 12). The Minister retains authority to inquire into
scribed qualification and is appointed for that purpose by matters (section 59), appoint a public administrator if
a regional health authority and the Cancer Agency, audit necessary (section 60), and approve general and staff
the accounts of a regional health authority or the Cancer practitioner by-laws (sections 42–44).
Agency at least once in every fiscal year. Each regional
health authority and the Cancer Agency must annually Funding for hospitals is included in the funding provided
submit to the Minister of Health a detailed, audited set to regional health authorities.
of financial statements.
A comprehensive range of insured services is provided by
The most recent audits were for the year ending March hospitals. These may include: public ward accommoda-
31, 2016. The audits of the Government of Saskatchewan, tion; necessary nursing services; the use of operating room
regional health authorities and Saskatchewan Cancer and case room facilities; required medical and surgical
Agency are tabled in the Saskatchewan Legislature each materials and appliances; x-ray, laboratory, radiological
year. The reports are available to the public directly from and other diagnostic procedures; radio-therapy facilities;
each entity and are available on their websites. anaesthetic agents and the use of anaesthesia equip-
ment; physiotherapeutic procedures; all drugs, biological
The Office of the Provincial Auditor for Saskatchewan and related preparations required for hospitalized pa-
also prepares reports to the Legislative Assembly of tients; and services rendered by individuals who receive
Saskatchewan. These reports are designed to assist remuneration from the hospital.
the government in managing public resources and to

Hospitals are grouped into the following five categories: must also advise beneficiaries that the physician
Community Hospitals; Northern Hospitals; District services to be provided are not insured and that the
Hospitals; Regional Hospitals; and Provincial Hospitals, beneficiary is not entitled to be reimbursed for those
so people know what they can expect at each hospital. services. Written acknowledgement from the beneficiary
While not all hospitals will offer the same kinds of indicating that he or she understands the advice given by
services, reliability and predictability means: the physician is also required.
• it is widely understood which services each hospital As of March 31, 2016, there were no opted-out
offers; and physicians in Saskatchewan.
•
these services will be provided on a continuous Insured physician services are those that are medically
basis, subject to the availability of appropriate health necessary, are covered by the Medical Services Plan of the
providers. Ministry of Health, and are listed in the Physician Payment
Schedule of the Saskatchewan Medical Care Insurance
Regional health authorities have the authority to change Payment Regulations (1994) of the Saskatchewan Medical
the manner in which they deliver insured hospital Care Insurance Act.
services based on an assessment of their population
health needs, available health providers and financial A process of formal discussion between the Medical
resources. Services Plan and the Saskatchewan Medical Association
addresses new insured physician services and definition
The process for adding a hospital service to the list of or assessment rule revisions to existing selected services.
services covered by the health care insurance plan The Executive Director of the Medical Services Branch
involves a comprehensive review, which takes into manages this process. When the Medical Services Plan
account such factors as service need, anticipated covers a new insured physician service, or a change is
service volume, health outcomes by the proposed and made to an existing service, a regulatory amendment is
alternative services, cost and human resource made and the changes are reflected in the Physician
requirements, including availability of providers as well Payment Schedule.
as initial and ongoing competency assurance demands.
A regional health authority initiates the process and, Although formal public consultations are not held, any
depending on the specific service request, it could member of the public may make recommendations
include consultations involving several branches within about physician services to be added to the Medical
the Ministry of Health as well as external stakeholder Services Plan.
groups such as other regional health authorities, service
providers and the public. 2.3 Insured Surgical-Dental Services
Dentists may opt out or not participate in the Medical
2.2 Insured Physician Services Services Plan, but if doing so, they must opt out of all
Sections 8 and 9 of the Saskatchewan Medical Care insured surgical-dental services. The dentist must also
Insurance Act enable the Minister of Health to establish advise beneficiaries that the surgical-dental services to
and administer a plan of medical care insurance for be provided are not insured and that the beneficiary is
provincial residents. All fee items for physicians can not entitled to reimbursement for those services. Written
be found in the Physician Payment Schedule at www. acknowledgement from the beneficiary indicating that
saskatchewan.ca. he or she understands the advice given by the dentist
is also required. There were no opted-out dentists in
As of March 31, 2016, there were 2,375 physicians Saskatchewan as of March 31, 2016.
licensed to practice in the province and eligible to
participate in the Medical Care Insurance Plan. Of these, Insured surgical-dental services are limited to: services in
1,251 (52.7 per cent) were family practitioners and 1,124 connection with maxillo-facial surgery required as a result
(47.3 per cent) were specialists. of trauma; treatment services for the orthodontic care
of cleft palate; extraction of teeth when medically
Physicians may opt out or not participate in the Medical required; surgical treatment for temporomandibular
Services Plan, but if doing so, they must fully opt out of joint dysfunction; dental implants in exceptional circum-
all insured physician services. The opted-out physician stances (tumours and congenital) upon request from
90
specialist in oral maxillofacial surgery and prior approval through consultations with regional health authorities,
from Medical Services Branch; and certain services physicians and dentists.
in connection with abnormalities of the mouth and
surrounding structures. Insured hospital services could be de-insured by the
government if they were determined to be no longer
Surgical-dental services can be added to the list of medically necessary. The process is based on discus-
insured services covered under the Medical Services sions among regional health authorities, practitioners,
Plan through a process of discussion and consulta- and officials from the Ministry of Health.
tion with provincial dental surgeons. The Executive
Director of the Medical Services Branch manages the Insured physician services could be de-insured if they
process of adding a new service. Although formal public were determined not to be medically required. The pro-
consultations are not held, any member of the public may cess is based on consultations with the Saskatchewan
recommend that surgical-dental services be added to the Medical Association and managed by the Executive
Medical Services Plan. Director of the Medical Services Branch.
As of March 31, 2016, there were approximately 500 Insured surgical-dental services could be de-insured if
practicing dentists and dental surgeons located in all they were determined not to be medically necessary.
major centres in Saskatchewan. Seventy-nine provided The process is based on discussion and consultation
services insured under the Medical Services Plan. with the dental surgeons of the province, and is managed
by the Executive Director of the Medical Services Branch.
Surgical-Dental Services Formal public consultations about de-insuring hospital,
Uninsured hospital, physician and surgical-dental physician or surgical-dental services may be held if war-
services in Saskatchewan include: in-patient and out- ranted. There were no services de-insured in 2015-2016.
patient hospital services provided for reasons other than
medical necessity; the extra cost of private and semi-
private hospital accommodation not ordered by a 3.0 UNIVERSALITY
physician; physiotherapy and occupational therapy 3.1 Eligibility
services not provided by or under contract with a The Saskatchewan Medical Care Insurance Act (sections
regional health authority; services provided by health 2 and 12) and the Medical Care Insurance Beneficiary
facilities other than hospitals unless through an agree- and Administration Regulations define eligibility for in-
ment with a regional health authority and licensed under sured health services in Saskatchewan. Section 11 of
the MRI Facilities Licensing Act or the Health Facilities the Act requires that all residents register for provincial
Licensing Act; non-emergency insured hospital, physi- health coverage.
cian or surgical-dental services obtained outside Canada
without prior written approval; non-medically required Eligibility is limited to residents. A “resident” means a
elective physician services; surgical-dental services person who is legally entitled to remain in Canada,
that are not medically necessary; and services received who makes his or her home and is ordinarily present in
under other public programs including the Workers’ Saskatchewan, or any other person declared by the
Compensation Act, the federal Department of Veteran Lieutenant Governor-in-Council to be a resident. Canadian
Affairs and the Mental Health Services Act. citizens and permanent residents of Canada relocating
from within Canada to Saskatchewan are generally
As a matter of policy and principle, insured hospital, eligible for coverage on the first day of the third month
physician and surgical-dental services are provided to following establishment of residency in Saskatchewan.
residents on the basis of assessed clinical need.
Compliance is periodically monitored through consulta- Returning Canadian citizens, the families of returning
tion with regional health authorities, physicians and members of the Canadian Forces, international students,
dentists. There are no charges allowed in Saskatchewan and international workers are eligible for coverage on
for insured hospital, physician or surgical-dental services. establishing residency in Saskatchewan, provided that
Charges for enhanced medical services or products are residency is established before the first day of the third
permitted only if the medical service or product is not month following their admittance to Canada.
deemed medically necessary. Compliance is monitored

The following persons are not eligible for insured health 4.2 Coverage During Temporary Absences in Canada
services in Saskatchewan: Section 3 of the Medical Care Insurance Beneficiary and
Administration Regulations of the Saskatchewan Medical
•
members of the Canadian Forces, federal inmates, Care Insurance Act prescribes the portability of health
refugee claimants, visitors to the province; and insurance provided to Saskatchewan residents while
temporarily absent within Canada.
• persons eligible for coverage from their home province
or territory for the period of their stay in Saskatchewan In 2015-2016 Saskatchewan amended Regulations to
(e.g., students and workers covered under temporary ab- increase the amount of time residents are allowed to be
sence provisions from their home province or territory). out-of-province while still maintaining their health care
benefits. Residents are now able to maintain health
Such people become eligible for coverage as follows:
coverage after spending a maximum of seven months
• discharged members of the Canadian Forces, if stationed outside of Saskatchewan. Residents were only allowed
in or resident in Saskatchewan on their discharge date; to be absent for a maximum of six months over any
12 month period before their health benefits were
• released federal inmates (this includes those prison- discontinued. The new policy took effect January 1, 2016.
ers who have completed their sentences in a federal
penitentiary and those prisoners who have been Section 6.6 of the Health Administration Act provides
granted parole and are living in the community); and the authority for paying in-patient hospital services to
Saskatchewan beneficiaries temporarily residing outside
• refugee claimants, on receiving Convention Refugee the province. Section 10 of the Saskatchewan Medical
status (immigration documentation is required). Care Insurance Payment Regulations (1994) provides
payment for physician services to Saskatchewan benefi-
The number of persons registered for health services in ciaries temporarily residing outside the province.
Saskatchewan on June 30, 2015, was 1,154,257.
Continued coverage during a period of temporary
3.2 Other Categories of Individuals absence is conditional upon the registrant’s intent to
Other categories of individuals who are eligible for in- return to Saskatchewan residency immediately on expi-
sured health service coverage include persons allowed ration of the approved absence period as follows:
to enter and remain in Canada under authority of a work
permit, study permit or Minister’s permit issued by • education: for the duration of studies at a recognized
Immigration, Refugees and Citizenship Canada. Their educational facility (confirmation by the facility of
accompanying family may also be eligible for insured full-time student status and expected graduation date
health service coverage. are required);
Refugees are eligible on confirmation of Convention • employment of up to 12 months (no documentation

status combined with a study or work permit, Minister’s required); and
permit or permanent resident or landed immigrant record.
• vacation and travel of up to 12 months.
4.0 PORTABILITY Saskatchewan has bilateral reciprocal billing agreements

with all provinces for hospital services. Quebec does not
4.1 Minimum Waiting Period participate in reciprocal billing of physician services.
In general, insured persons from another province or
territory who move to Saskatchewan are eligible on 4.3 Coverage During Temporary
the first day of the third month following establishment Absences Outside Canada
of residency. However, where one spouse arrives in Section 3 of the Medical Care Insurance Beneficiary and
advance of the other, the eligibility for the later arriving Administration Regulations of the Saskatchewan Medical
spouse is established on the earlier of a) the first day of Care Insurance Act prescribes the portability of health
the third month following arrival of the second spouse; insurance provided to Saskatchewan residents who are
or b) the first day of the thirteenth month following the temporarily absent from Canada.
establishment of residency by the first spouse.
92
Continued coverage for students, temporary workers, Out-of-Country

vacationers and travellers during a period of temporary
absence from Canada is conditional on the registrant’s If a specialist physician refers a patient outside Canada
intent to return to Saskatchewan residence immediately for treatment not available in Saskatchewan or another
on the expiration of the approved period as follows: province, the referring specialist must seek prior approval
from the Medical Services Plan of the Ministry of Health.
• education: for the duration of studies at a recognized The Saskatchewan Cancer Agency is consulted for out-
educational facility (confirmation by the facility of full- of-country cancer treatment requests. If approved, the
time student status and expected graduation date Ministry of Health will pay the full cost of treatment,
are required); excluding any items that would not be covered in
Saskatchewan.
• contract employment of up to 24 months; and
• vacation and travel of up to 12 months. 5.0 ACCESSIBILITY

Section 3 of the Medical Care Insurance Beneficiary and 5.1 Access to Insured Health Services
Administration Regulations provides open-ended tem- To ensure that access to insured hospital, physician and
porary absence coverage for persons whose principal surgical-dental services is not impeded or precluded by
place of residence is in Saskatchewan, but who are not financial barriers, extra-billing by physicians or dental
able to satisfy the annual six months physical presence surgeons, and user charges by hospitals for insured
requirement because the nature of their employment health services are not allowed in Saskatchewan.
requires travel from place to place outside Canada (e.g.,
Pursuant to section 18(1.1) of the Saskatchewan Medical
cruise line workers).
Care Insurance Act, no physician or other person who
Section 6.6 of the Health Administration Act provides the provides an insured service to a beneficiary shall
authority under which a resident is eligible for health demand or accept payment for that service in an amount
coverage when temporarily outside Canada. In summary, that he knows exceeds the payment to be made for that
a resident is eligible for medically necessary hospital service prescribed in the Saskatchewan Medical Care
services at the rate of $100 per in-patient and $50 per Insurance Regulations.
out-patient visit per day.
Building on the success of the Saskatchewan Surgical
4.4 Prior Approval Requirement Initiative which significantly reduced patient wait times
Out-of-Province for surgery, the health system is working to strengthen
coordination, communication, and referral guidelines to
The Saskatchewan Ministry of Health covers most better coordinate services to ensure patients have timely
hospital and medical out-of-province care received by its access to the most appropriate specialist and diagnostic
residents in Canada through reciprocal billing arrange- services. By reducing the wait time for a consult with a
ments. These arrangements mean that residents do specialist or diagnostic services (such as MRI and CTs),
not need prior approval and may not be billed for most patients will be able to access treatment sooner.
services received in other provinces or territories while
travelling within Canada. The cost of travel, meals and In May 2009, the Government of Saskatchewan released
accommodation are not covered. the Physician Recruitment Strategy in an effort to address
province-wide physician shortages. In 2015-2016 funding
Prior approval is required for the following services supported several recruitment initiatives:
provided out-of-province:
• The provincial plan for distributed medical education
• alcohol and drug, mental health, rehabilitation, problem continued to be developed and rolled out with the
gambling services, home care, and certain rehabilita- goal of increasing the number of medical seats in rural
tive services. centres. Post-graduate seats were offered in Regina,
Prince Albert, Swift Current, North Battleford, La Ronge
Prior approval from the Ministry must be obtained by the and Moose Jaw.
patient’s specialist.

• The Physician Recruitment Agency of Saskatchewan Payments to regional health authorities for delivering
(saskdocs), created in 2009, continued to provide services are made pursuant to section 8 of the Regional
recruitment expertise to communities, physician prac- Health Services Act. The legislation provides the authority
tices and health agencies. for the Minister of Health to make grants to regional
health authorities and health care organizations for the
•
The Saskatchewan International Physician Practice purposes of the Act, and to arrange for providing services
Assessment program worked to ensure that foreign- in any area of Saskatchewan if it is in the public interest to
trained physicians were assessed with sufficient rigor do so.
and patients received safe, high-quality care.
Regional health authorities provide an annual report on
Other Programs the aggregate financial results of their operations.
The Family Physician Comprehensive Care Program is
intended to support recruitment and retention of family
6.0 RECOGNITION GIVEN
physicians by recognizing those physicians who provide a
full range of services to their patients and the continuity TO FEDERAL TRANSFERS
of care that result from these comprehensive services.
The Government of Saskatchewan publicly acknowledges
5.2 Physician Compensation federal contributions provided through the Canada Health
Section 6 of the Saskatchewan Medical Care Insurance Transfer in the Ministry of Health’s 2015-2016 Annual
Payment Regulations (1994) outlines the obligation of the Report, the 2016-2017 Provincial Budget and related docu-
Minister of Health to make payments for insured services ments, the 2014-2015 Public Accounts, and the Quarterly
in accordance with the Physician Payment Schedule and and Mid-Year Financial Reports. These documents have
the Dentist Payment Schedule. been tabled in the Legislative Assembly and are publicly
available online to all Saskatchewan residents. Federal
Fee-for-service is the most widely used method of contributions are also noted in news releases and issue
compensating physicians for insured health services papers, speeches and remarks made at conferences,
in Saskatchewan, although sessional payments, salary, meetings and public policy forums throughout the year.
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 2015-2016 amounted
to $1.007 billion: $535.2 million for fee-for-service bill-
ings; $31.1 million for Specialist Emergency Coverage
Programs; and $375.1 million in non-fee-for-service
expenditures. There was also an additional $65.7 million
for other Saskatchewan Medical Association and bursary
programs.

Funding to regional health authorities is based on his-
torical funding levels adjusted for inflation, collective
agreement costs and utilization increases. Each regional
health authority is given a global budget and is respon-
sible for allocating funds within that budget to address
service needs and priorities identified through its needs
assessment processes.
Regional health authorities may receive additional funds

for providing specialized hospital programs (e.g., renal
dialysis, specialized medical imaging services, special-
ized respiratory services, and surgical services), or for
providing services to residents from other health regions.
94
REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 66 66 66 66 66

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Payments to private for-profit facilities for not available3 not available3 not available3 not available3 not available3

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments, out-patients ($) 3,203,800 1,511,300 1,606,100 480,300 5
1,136,300
Saskatchewan’s numbers as of June 30, 2015.

1
This number includes estimated government funding to regional health authorities in their annual audited financial statements.
2
—Includes acute care services, specialized hospital services, and in-hospital specialist services.
—Does not include in-patient mental health, or addiction treatment services.
—Does not include payments to Saskatchewan Cancer Agency for out-patient chemotherapy and radiation.
Private facilities providing surgical services and computed tomography scans receive payments for these services
3
under contract with regional health authorities. The Ministry of Health does not provide payments to these facilities.
4 Decrease in 2014-2015 due to decrease in in-patient claims and corresponding mix of procedure cost.
5 Decrease in 2014-2015 was due to a decrease in out-of-country treatments.


Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
physicians (#)
physicians (#)
physicians (#)

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 32,103,002 33,658,928 35,703,160 37,220,270 40,339,800

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services (#) not available not available not available not available not available
Total payments ($) 2,279,100 1,199,100 1,484,200 1,416,300 996,600

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 1,719,770 1,710,397 1,669,803 1,870,512 2,146,101
6 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.
96
CHAPTER 3 | ALBERTA
AL B ERTA
The Minister of Health, the Associate Minister 2.0 COMPREHENSIVENESS
of Health, the Department of Health (Alberta
Health) and the Regional Health Authority
In Alberta, Alberta Health Services (AHS) is the
(Alberta Health Services) play key roles in agency responsible to the Minister of Health for
Alberta’s health care system. All entities work ensuring the provision of insured hospital services. The
together to deliver better care and improve Hospitals Act, the Hospitalization Benefits Regulation
population outcomes in a sustainable way. The (AR 244/1990), the Health Care Protection Act, and the
Health Care Protection Regulation (AR 208/2000)
goal is for Albertans to get the right care, in the
govern the provision of insured services by hospitals or
right place, at the right time, by the right health designated non-hospital surgical facilities. During 2015-
care team, with the right information. 2016, no amendments were made to the legislation
regarding insured hospital services. A directory of
approved hospitals in Alberta can be found at: www.
health.alberta.ca/services/health-benefits-services.html.
1.0 PUBLIC ADMINISTRATION The publicly funded services provided by approved
hospitals in Alberta include all of the hospital services
1.1 Health Care Insurance Plan and Public Authority
listed in the Canada Health Act. The insured hospital
Alberta Health administers and operates the Alberta
services range from the most advanced levels of
Health Care Insurance Plan (AHCIP) in accordance with
diagnostic and treatment services for in-patients and out-
the Canada Health Act. Since 1969, the Alberta Health
patients, to routine care and management of patients
Care Insurance Act has governed the operation of the
with previously diagnosed chronic conditions. The
AHCIP. The Minister of Health, working in conjunction
benefits available to hospital patients in Alberta are
with the appropriate stakeholders, determines which
established in the Hospitalization Benefits Regulation
services are covered by the AHCIP.
(AR 244/1990). The Regulation is available at: www.
1.2 Reporting Relationship health.alberta.ca/about/health-legislation.html.
The Minister of Health is accountable for the AHCIP. The
The list of insured services included in the Regulations is
Fiscal Planning and Transparency Act (which replaced
intended to be both comprehensive and generic thereby
the Financial Management Act in 2015), provides a
limiting the need for routine review and updating. Any
framework for government budgeting and fiscal plan-
listing or delisting of an insured service is undertaken
ning. The Minister is required to prepare an annual
without public consultation.
report, which must include the audited financial state-
ments. The 2015-2016 Annual Report of the Ministry of 2.2 Insured Physician Services
Health was released to the public on June 29, 2016. The Alberta Health Care Insurance Act governs the
payment of physicians for insured physician services
under section 6. Only physicians who meet the require-
The Auditor General of Alberta audits all government
ments stated in the Act are permitted to make a claim
ministries, departments, regulated funds and provincial
for payment of benefits for providing insured services
agencies, and is responsible for assuring the public that
under the AHCIP.
the government’s financial reporting is credible. The
Auditor General of Alberta completed an audit of the Alberta had 9,331 physicians participating under the
Ministry of Health on June 6, 2016, and indicated that AHCIP as of March 31, 2016. Within this, 7,750 physicians
the consolidated financial statements present fairly, in were paid exclusively under fee-for-service, 746 were
all material respects, the financial position and results compensated solely under an Alternative Relationship
of operations for the year that ended March 31, 2016. Plan (ARP) and the remaining 835 physicians received
compensation from both fee-for-service and ARP.

CHAPTER 3 | ALBERTA
Before being registered with the AHCIP, a physician Although there is no formal agreement with dentists,
must complete the appropriate registration forms and Alberta Health meets with members of the Alberta
include a copy of his or her licence issued by the College Dental Association and College to discuss changes to
of Physicians and Surgeons of Alberta. the Schedule of Oral and Maxillofacial Surgery Benefits;
there is no public consultation. All changes to the benefit
Under section 8 of the Alberta Health Care Insurance schedule require the approval of the Minister of Health.
Act, all physicians are deemed to be opted into the
AHCIP. Under section 8(2) a physician may opt out Under section 7 of the Alberta Health Care Insurance Act,
of the AHCIP by (a) notifying the Minister in writing all dentists are deemed to have opted into the AHCIP.
indicating the effective date of the opting out, (b) Under section 7(2) a dentist may opt out of the AHCIP
publishing a notice of the proposed opting out in a by (a) notifying the Minister in writing indicating the
newspaper having general circulation in the area in which effective date of the opting out, (b) publishing a notice of
the physician practices, and (c) posting a notice of the the proposed opting out in a newspaper having general
proposed opting out in a part of the physician’s office to circulation in the area in which the dentist practices, and
which patients have access at least 180 days prior to the (c) posting a notice of the proposed opting out in a part
effective date of the opting out. of the dentist’s office to which patients have access at
least 30 days prior to the effective date of the opting out.
By opting out of the AHCIP, a physician agrees that,
commencing on the opt-out effective date, they will By opting out of the AHCIP, a dentist agrees that,
not participate in the publicly funded health system. commencing on the opt-out effective date, they will not
This means that the physician cannot make a claim participate in the publicly funded health system. This
from the AHCIP for payment for providing what would means that the dentist cannot make a claim from the
otherwise be publicly funded health services and the AHCIP for payment for providing what would otherwise
patient cannot seek reimbursement for any amounts be publicly funded surgical-dental services and the
paid by the patient for receiving health services from the patient cannot seek reimbursement for any amounts paid
opted-out physician. As of March 31, 2016, there was by the patient for receiving surgical-dental services from
one opted out physician in the province. the opted-out dentist. As of March 31, 2016, no dentists
were opted-out of the AHCIP.
Section 12 of the Alberta Health Care Insurance
Regulation lists services that are not considered basic 2.4 Uninsured Hospital, Physician,
or extended health services. The Medical Benefits and Surgical-Dental Services
Regulation establishes the benefits payable for insured Section 12 of the Alberta Health Care Insurance Regulation
medical services provided to a resident of Alberta. lists services that are not considered basic or extended
Descriptions of those services are set out in the Schedule health services unless otherwise approved by the Minister.
of Medical Benefits which can be accessed at www. Section 4(2) of the Hospitalization Benefits Regulation
health.alberta.ca/professionals/SOMB.html. No services provides a list of hospital services that are not considered
were added during 2015-2016. to be insured. Services not covered by the AHCIP include
cosmetic surgery, ambulance services, prescription
2.3 Insured Surgical-Dental Services drugs, routine dental care, routine eye examinations for
In Alberta, a small number of medically necessary oral residents 19 to 64 years of age, and third party medical
surgical and dental procedures are insured. These are services, such as medicals for employment, insurance
listed in the Schedule of Oral and Maxillofacial Surgery and sports.
Benefits, available at: www.health.alberta.ca/professionals/
allied-services-schedule.html. Routine dental care is not Section 8 of the Regional Health Authorities Act provides
covered by the AHCIP. authority for the Preferred Accommodation and Non
Standard Goods or Services Policy. The policy describes
The majority of dental procedures that can be billed to the Government of Alberta’s expectations of AHS and
the AHCIP can only be performed by a dentist certified guides the provision of preferred accommodation, and
as an oral and maxillofacial surgeon who meets the re- enhanced or non-standard goods and services. This
quirements stated in the Alberta Health Care Insurance policy framework requires AHS to provide 30 days
Act. Insured dental-surgical services must be performed advance notice to the Minister of Health’s designate
in either a hospital or a non-hospital surgical facility. regarding the categories of preferred accommodation
98
CHAPTER 3 | ALBERTA
offered and the charges associated with each category. In order to access insured services under the AHCIP,
AHS is also required to provide 30 days advance notice Alberta residents are required to register themselves
to the Minister of Health’s designate regarding any and their eligible dependents. Family members are
goods or services that will be provided as non-standard registered on the same account. Persons moving to
goods or services. AHS must also provide information Alberta should apply for coverage within three months
about the associated charge for these goods or services, of arrival or effective dates may be affected. For persons
and when applicable, the criteria or clinical indications moving to Alberta from within Canada, their registra-
that may qualify patients to receive it as a standard good tion is effective on the first day of the third month after
or service. Alberta’s policy for Preferred Accommodation their arrival. For persons moving to Alberta from outside
and Non-Standard Goods or Services is available at: www. Canada, their registration is effective the day they
health.alberta.ca/documents/preferred-accommodation- become an Alberta resident. The AHCIP process for
policy-2005.pdf. registering Albertans and issuing replacement health
cards requires registrants to provide documentation
that proves their identity, legal entitlement to be in
3.0 UNIVERSALITY Canada, and Alberta residency.
3.1 Eligibility As of March 31, 2016, there were 4,449,483 Alberta

Under the terms of the Alberta Health Care Insurance residents registered with the AHCIP. As per the Health
Act, Alberta residents are eligible to receive publicly Insurance Premiums Act, a resident may opt out of the
funded health care services under the Alberta Health AHCIP by filing a declaration with the Minister of Health.
Care Insurance Plan (AHCIP). A resident is defined as As of March 31, 2016, there were 248 Alberta residents
a person who is lawfully entitled to be or to remain in who were opted-out of the AHCIP.
Canada, who makes the province their home and is
ordinarily present in Alberta, and any other person 3.2 Other Categories of Individuals
deemed by the Regulations to be a resident. The term Under the Alberta Health Care Insurance Regulation, a
“resident” does not include a tourist, transient or visitor person may be deemed a resident for the purpose of
to Alberta. AHCIP coverage if they are residing in Alberta to work,
study, or are the spouse or partner or dependent of
Persons moving permanently to Alberta from outside someone who is here to work or study. A Canada Entry
Canada are eligible for coverage if they have perma- Document such as a Work Permit, Study Permit or Visitor
nent resident status, are returning landed immigrants, Record (that limits length of stay) is required as proof of
or are returning Canadian citizens. Persons in Alberta their legal entitlement to be, and remain, in Canada.
on an approved Canada entry document may also be Deemed residents must intend on residing in Alberta
eligible for coverage under the AHCIP, and their eligibility is for 12 months or more. There were 82,152 people
reviewed on a case-by-case basis. covered by the AHCIP under these conditions as of
March 31, 2016.
A resident is not entitled to AHCIP coverage if the res-
ident is a member of the Canadian Armed Forces or a Individuals who hold a Study Permit that does not
person serving a term in a federal penitentiary as defined indicate a school in Alberta are required to provide proof
in the Corrections and Conditional Release Act. These of registration from the accredited school they are
residents receive health care coverage from the federal attending. Open or employer-specific work permits
government. Spouses or partners and dependents of must be valid for six months or more. Employer-specific
these residents are provided with AHCIP coverage if work permits must state the individual is employed by
they are Alberta residents. a company operating in Alberta. With the exception of
clergy, athletes or members of the British army, individ-
The AHCIP will cover individuals released within uals with a Visitor Record must be the spouse or partner
Alberta from the Canadian Armed Forces or federal or dependent of an eligible resident or deemed resident.
penitentiaries, effective the date of release, if notified
within three months. If individuals are released in Individuals whose Canada Entry Document has the
another part of Canada, they are eligible for coverage on remark ‘does not confirm temporary resident status’,
the first day of the third month after becoming a are not eligible for AHCIP coverage.
resident of Alberta.

CHAPTER 3 | ALBERTA
Landed immigrants who have a landed status document territory, Alberta will reimburse for the insured service
or proof of Permanent Resident Status and Convention provided at the host province’s or territory’s rates for med-
Refugees who have a positive Notice of Decision letter ical services and the applicable rate for hospital services.
are also eligible for AHCIP coverage. Refugee Claimants
are not eligible for AHCIP coverage. In 2015-2016, no amendments were made to the legisla-
tion regarding portability within Canada. More information
Children born to Canadian citizens who are temporarily on coverage during temporary absences outside Alberta
absent from Alberta (and have maintained their is available at: www.health.alberta.ca/AHCIP/outside-
coverage) are eligible for AHCIP coverage. Documenta- coverage.html.
tion may be required.
Section 16 of the Hospitalization Benefits Regulation ad-
dresses payment for hospital services obtained outside
4.0 PORTABILITY of Alberta but within Canada. Section 4 of the Medical
Benefits Regulation addresses payment of physician
4.1 Minimum Waiting Period services obtained outside of Alberta but within Canada.
Under the Alberta Health Care Insurance Plan (AHCIP), These sections were not amended in 2015-2016.
generally persons moving permanently to Alberta from
another part of Canada are eligible for coverage on the 4.3 Coverage During Temporary Absences
first day of the third month following their arrival. Outside Canada
The AHCIP provides coverage to eligible Alberta residents
4.2 Coverage During Temporary Absences who are temporarily absent from Canada. A person is
in Canada considered to be temporarily absent from Alberta if the
The AHCIP provides coverage for eligible Alberta person stays outside Canada for a period that will not
residents who temporarily leave Alberta for other parts exceed six consecutive months, and the person intends
of Canada. A person is considered temporarily absent to return to and maintain permanent residence in Alberta
from Alberta if the person stays in another province or on the conclusion of their stay outside Alberta.
territory for a period that will not exceed 12 consecutive
months and where the person intends to return to and Individuals who are routinely absent from Alberta every
maintain permanent residence in Alberta on the conclu- year normally must spend a cumulative total of 183 days
sion of their stay outside Alberta. in a 12-month period in Alberta to maintain continuous
coverage. Exceptions may be considered by Alberta
Individuals who are routinely absent from Alberta every Health depending on the individual circumstance. Individ-
year normally must spend a cumulative total of 183 days uals may also remain eligible for coverage if, on a recurring
in a 12 month period in Alberta to maintain continuous basis, they are absent from Alberta for up to 212 days in
coverage. Individuals not present in Alberta for the re- a 12-month period for the purpose of vacation.
quired 183 days may be considered residents of Alberta
if they satisfy Alberta Health of their permanent and Individuals leaving the province temporarily on extended
principal place of residence within the province. Individuals vacations, or for temporary employment, may be eligi-
may also remain eligible for coverage if, on a recurring ble for coverage for 24 to 48 consecutive months. They
basis, they are absent from Alberta for up to 212 days in should contact Alberta Health to enquire about their
a 12 month period for the purpose of vacation. coverage. Students attending an accredited educational
institute outside Canada on a full-time basis are entitled
Alberta participates in the interprovincial hospital and to coverage for the duration of their studies providing they
medical reciprocal billing agreements. All provinces and intend to reside in Alberta at the conclusion of their studies.
territories, except Quebec, participate in medical recip-
rocal agreements. These agreements were established The maximum amount payable for out-of-country in-patient
to minimize complex billing processes and to help hospital services is $100 (CAD) per day (not including
ensure timely payments to physicians and hospitals day of discharge). The maximum hospital out-patient visit
when they provide services to residents from other rate is $50 (CAD), with a limit of one visit per day. The
provinces or territories. Under these agreements, where only exception is haemodialysis received as an out-patient,
an eligible Albertan receives an insured physician service which until March 31, 2016, was paid at a maximum of
or hospital service in another participating province or $453 per visit, with a limit of one visit per day. Effective
100
CHAPTER 3 | ALBERTA
April 1, 2016, the rate increased from $453 to $462 per Section 9 of the Alberta Health Care Insurance Act pro-
visit. Physician and dental specialist or oral surgeon hibits extra-billing. No physician or dentist who is opted
services are paid according to Alberta rates. Funding into the Alberta Health Care Insurance Plan (AHCIP) and
may also be available through the Out-of-Country Health who provides insured services to a person shall charge
Services Committee. This committee evaluates requests or collect from any person an amount in addition to the
made by Alberta physicians or dentists for eligible Alberta benefits payable by the Minister for those insured services.
residents to be considered for funding of insured ser-
vices covered under the AHCIP that are not available in Health infrastructure is important in ensuring current and
Canada. More information on coverage during temporary future health care needs are met. The Ministries of Health
absences outside Canada is accessible at: www.health. and Infrastructure share the responsibility for planning
alberta.ca/AHCIP/coverage-outside-Canada.html. and management of the Health Facilities Capital Program
and projects. The Ministry of Health is responsible for
Section 16 of the Hospitalization Benefits Regulation also setting strategic directions and implementing health
addresses payment for goods and services provided by policy, legislation, standards and providing global
hospitals or approved facilities outside of Canada. Section operating funding to AHS. AHS identifies and prioritizes
5 of the Medical Benefits Regulation addresses payment health service needs requiring capital development. The
of physician services obtained outside Canada. These Government of Alberta supports health infrastructure by
sections were not amended in 2015-2016. funding capital development and the infrastructure
maintenance program. The Ministry of Infrastructure is
4.4 Prior Approval Requirement responsible for the design, construction and delivery of
Prior approval is not required for elective (non-emergency) major health Capital Projects throughout the province. In
insured services received in another Canadian province or 2015-2016, projects were completed in Calgary’s Foothills
territory, except for high-cost items not included in Medical Centre, Lethbridge’s Chinook Regional Hospital,
reciprocal agreements such as gamma knife surgery. and health centres in Raymond and Taber. Work
continued on health facility projects in Edson, Grande
Prior application is required for elective services received
Prairie, High Prairie, Medicine Hat, Fort McMurray,
out-of-country and approval may only be given through
Edmonton, and Calgary. Health legislation also stipulates
the Out-of-Country Health Services Committee for insured
the requirements for the purchase and disposition of
services that are medically required, are not experimental,
assets and properties and the general provisions for
and are not available in Alberta or elsewhere in Canada.
health infrastructure.

5.0 ACCESSIBILITY The Alberta Health Care Insurance Act governs the
5.1 Access to Insured Health Services payment of physicians. Physicians are compensated
The Government of Alberta is committed to meeting the through the AHCIP on a volume-driven, fee-for-service
health care needs of all Albertans. To ensure Albertans basis or through the use of Alternative Relationship
have the best possible access to primary health care Plans (ARPs).
services, the Ministry funds Primary Care Networks ARPs are used by specialists and family physicians and
(PCNs). PCNs are inter-disciplinary teams made up of offer alternative compensation models to the traditional
family physicians and other health care professionals fee-for-service payment system. The purpose of ARPs
who work with Alberta Health Services (AHS) to coordi- is to enhance physician recruitment and retention,
nate the delivery of primary health care services for team-based approaches to service delivery, access to
their patients. Each network has the flexibility to develop services, patient satisfaction, and value for money.
programs and provide services to meet the specific ARPs support innovative health care delivery which will
needs of patients. Access to health care services can be result in better health outcomes. The predictable funding
limited by geography, hours of operation, and wait times. provided by ARPs enables physician groups to
As of March 31, 2016, there were 42 PCNs operating in recruit new physicians to their programs and retain their
Alberta, over 3.5 million Albertans were enrolled in a services while in some cases providing additional funding
PCN, and of 4,795 General Practitioners, 3,532 were to support service delivery.
registered providers in PCNs.

CHAPTER 3 | ALBERTA
Alberta Health and the Alberta Medical Association en- for the provision of insured surgical services as con-
tered into the Alberta Medical Association Agreement templated in the proposed agreement;
(AMAA) in 2013, which was retroactive to April 1, 2011. The
financial terms of the AMAA establish set increases to the • that the provision of the insured surgical services as
insured services rates for seven years (from 2011 to 2018). contemplated under the proposed agreement would
Alberta Health and the Alberta Medical Association will not have an adverse impact on the publicly funded and
negotiate new financial terms for April 1, 2018 onwards. publicly administered health system in Alberta;
5.3 Payments to Hospitals • there is an expected public benefit in providing the in-
Alberta’s public hospitals are operated by Alberta Health sured surgical services as contemplated under the
Services (AHS) or by non-profit organizations under ser- proposed agreement, considering factors such as (i)
vice agreements with AHS. In Alberta, public hospitals access to such services, (ii) quality of service, (iii) flexi-
are operated in accordance with the Hospitals Act. bility, (iv) the efficient use of existing capacity, and (v)
The Health Care Protection Act prohibits the operation of cost effectiveness and other economic considerations;
private hospitals.
• that AHS has an acceptable business plan in respect of
The Regional Health Authorities Act governs the funding the proposed agreement showing how the health au-
of AHS, Alberta’s single regional health authority. The thority will pay for the facility services to be provided;
Ministry of Health funds AHS through base operating
• that the proposed agreement indicates performance
funds provided twice each month. AHS determines
expectations and related performance measures for
funding for individual hospitals and designated Non
the insured surgical services and facility services to
Hospital Surgical Facilities (NHSFs).
be provided; and
The Health Care Protection Act governs the provision of
•
that the proposed agreement contains provisions
insured and uninsured surgical services performed in
showing how physicians’ compliance with the Health
public hospitals and NHSFs. The Act prohibits queue-
Professions Act and Regulations under that Act, by-
jumping. Specifically, no person shall give or accept any
laws, code of ethics and standards of practice of the
money or other valuable consideration, pay for or accept
College of Physicians and Surgeons of Alberta, as
payment for enhanced medical goods or services or
they relate to conflict of interest and other ethical
non-medical goods or services, or provide an uninsured
issues in respect of the operation of the facility, will
surgical service for the purpose of giving any person
be monitored.
priority for the receipt of an insured surgical service.
Access to insured surgical services is based on medical Pursuant to the terms of any agreement between AHS
need of patients and determined by physicians. and a NHSF operator, AHS agrees to pay a contracted
“facility fee.” This fee covers certain services specified
The Minister of Health is required to approve a service
under the Health Care Protection Act that are medically
agreement between an NHSF operator and AHS in
necessary and are directly related to the provision of a
order for the facility to provide insured surgical services.
surgical service at an approved surgical facility.
Ministerial designation of a NHSF and accreditation by
Physicians who provide insured surgical services to
the College of Physicians and Surgeons of Alberta is
patients within an accredited NHSF are paid on a fee-for-
also required.
service basis through the AHCIP. These fees are the
According to the Health Care Protection Act, Ministerial same regardless of whether the physician provides the
approval for a facility services agreement shall not be insured service in a public hospital setting or in a NHSF.
given unless the Minister is satisfied:
• that the provision of insured surgical services as con- 6.0 RECOGNITION GIVEN TO
templated under the proposed agreement would be FEDERAL TRANSFERS
consistent with the principles of the Canada Health Act;
The Government of Alberta publicly acknowledged
• that there is a current need and that there will likely be the federal contributions provided through the Canada
an ongoing need in the geographical area to be served Health Transfer in its 2015–2016 publications.
102
CHAPTER 3 | ALBERTA
REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 225 226 225 225 225

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of private for-profit facilities not available not available not available not available not available
Payments to private for-profit facilities not available not available not available not available not available

IN ANOTHER PROVINCE OR TERRITORY 1
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA1,2

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Data reported reflect claims processed up to three months after the close of the fiscal year. Any claims processed after this date are not
1
reflected in the presented information.
These data do not include claims/payments for Alberta residents who have received health services through the Out-of-Country Health
2
Services Committee application process.

CHAPTER 3 | ALBERTA
INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY 3

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of participating physicians (#) 4 7,706 8,100 8,466 8,873 9,3315
Number of opted-out physicians (#) 6 0 0 0 0 0
Number of non-participating physicians (#) 0 0 1 1 1
Total payments for services provided by not available not available not available not available not available
physicians paid through all payment
methods ($)
Total payments for services provided by 2,450,159,476 2,584,944,346 2,778,382,882 3,033,392,142 3,336,009,256
physicians paid through fee-for-service ($)

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services (#) 7
616,786 751,061 663,164 694,373 795,738
Total payments ($) 7 27,960,901 27,940,698 30,710,409 32,203,224 34,639,878
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA7

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services (#) 42,643 8
39,317 8
33,804 8
36,290 8
not available9
Total payments ($) 2,573,1698 2,435,3058 2,189,2338 2,580,3638 not available9

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 6,293,750 7,077,327 7,317,869 8,208,000 9,185,042
3 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.
The physician count includes physicians who are fee-for-service, in Alternative Relationship Plans or receive compensation from both
4
fee-for-service and Alternative Relationship Plans.
7,750 of these are paid under fee-for-service, 746 under an Alternative Relationship Plan and the remaining 835 received compensation from
5
both fee-for-service and alternative relationship plans.
Alberta’s legislation provides that all physicians are deemed to be participating in the Alberta Health Care Insurance Plan, unless they opt
6
out in accordance with the procedure set out in section 8 of the Alberta Health Care Insurance Act.
These data do not include Alberta residents who have received health services through the Out-of-Country Health Services
7
Committee application process.
The 2011-2012 to 2014-2015 figures are calculated using a new methodology for capturing the out-of-country claim process. The change now
8
includes a one year lag from the fiscal year end to date of payment for more precise data.
Data for out of country physician services are still being processed for 2015-2016.
9
104
CHAPTER 3 | BRITISH COLUMBIA
BR IT I S H C O L U M B IA
British Columbia has a progressive and integrated enabling legislation for MSP. The purpose of the MPA is
health system that includes insured services fund- to preserve a publicly managed and fiscally sustainable
healthcare system for British Columbia, in which access
ed under the Canada Health Act, services funded
to necessary medical care is based on need and not on
wholly or partially by the Government of British an individual’s ability to pay.
Columbia and services regulated, but not funded,
by government. The Ministry of Health (the The Medical Services Commission (MSC) manages
MSP on behalf of the Government of British Columbia in
Ministry) has overall responsibility for ensuring
accordance with the MPA (section 3) and its Regulation.
that quality, appropriate, and timely health The function and mandate of the MSC is to facilitate
services are available to all British Columbians. reasonable access to quality medical care, healthcare,
and prescribed diagnostic facility services for British
To read more about British Columbia’s publicly Columbians.
funded health system; please refer to the Ministry
The MSC is a nine-member statutory body made up of
of Health 2016/17 — 2018/19 Service Plan:
three representatives from the Government of British
Columbia, three representatives from the Doctors of BC
http://www.bcbudget.gov.bc.ca/2016/sp/pdf/
(formerly the British Columbia Medical Association), and
ministry/hlth.pdf. three members from the public jointly nominated by the
Doctors of BC and government.
General hospital services are insured in British Columbia;

1.0 PUBLIC ADMINISTRATION however, these are not covered by MSP. General hospital
services are provided under the Hospital Insurance Act
1.1 Health Care Insurance Plan and Public Authority (section 8) and its Regulation; the Hospital Act (section 4);
The Ministry sets goals, standards, and performance and the Hospital District Act (section 20).
agreements for provincial health service delivery and
works with the province’s six health authorities to Since October 1, 2015, medically required laboratory
provide quality, appropriate, and timely health services to services for beneficiaries have been insured under the
British Columbians. Five regional health authorities LSA (sections 4 and 5). Prior to that date, the Hospital
deliver a full continuum of health services to meet the Insurance Act covered the provision of laboratory
needs of the population within their respective geo- services in hospital, while the MPA covered the
graphic regions. A sixth health authority, the Provincial provision of laboratory services provided in the commu-
Health Services Authority, is responsible for managing nity. However, the new legislation in no way changed
the quality, coordination, and accessibility of province- access to medically necessary laboratory tests, and the
wide health programs and services. The Ministry also Ministry of Health remains responsible for governance,
works in partnership with the First Nations Health accountability and provision of benefits for all laboratory
Authority to improve the health status of First Nations in services in the province.
British Columbia.
Most insured services are covered by the British The Ministry provides information in the Annual Service
Columbia Medical Services Plan (MSP), which is admin- Plan Report on the performance of British Columbia’s
istered by the Ministry. MSP covers medically required publicly funded health system. Tracking and reporting this
services provided by physicians and supplementary information is consistent with the Ministry’s strategic
healthcare practitioners, laboratory services (until October approach to performance planning and reporting and is
1, 2015, when all laboratory services became insured consistent with requirements contained in the provincial
under the Laboratory Services Act (LSA)), and diagnostic Budget Transparency and Accountability Act.
procedures. The Medicare Protection Act (MPA) is the

The MSC is accountable to the Government of British HIBC processes payments against fee items approved by
Columbia through the Minister of Health (the Minister); a the Ministry. The Ministry approves all payments before
report is published annually for the prior fiscal year which they are released.
provides an annual accounting of the business of the MSC,
its subcommittees, and other delegated bodies. This report MSP requires premiums to be paid by eligible residents.
is available at: www.gov.bc.ca/msppublications. Revenue Services of British Columbia (RSBC) performs
revenue management services, including account man-
1.3 Audit of Accounts agement, billing, remittance, and collection on behalf of
The Ministry is subject to audit of accounts and financial the Province of British Columbia (Ministry of Finance).
transactions through: The province remains responsible for and retains control
of all government administered collection actions.
•
Internal Audit and Advisory Services (IAAS); the
government’s internal auditor. IAAS determines the RSBC is required to comply with all applicable laws,
scope of the internal audits and timing of the audits. including the:
IAAS reports can be located on the following website
link: http://www.fin.gov.bc.ca/iaas/Audit_Reports.htm. • Ombudsperson Act;
•
The Office of the Auditor General (OAG) of British • Business Practices and Consumer Protection Act;
Columbia is responsible for conducting annual audits as
• Financial Administration Act; and
well as special audits and reports. The OAG reports its
findings to the Legislative Assembly. The OAG initiates •
Freedom of Information legislation (i.e., Freedom of
its own audits and determines the scope of its audits. Information and Protection of Privacy Act, the Personal
The Select Standing Committee on Public Accounts of Information Protection Act and the equivalent federal
the Legislative Assembly reviews the recommenda- legislation, if applicable).
tions of the OAG.
The OAG’s annual audit of the Ministry’s accounts and 2.0 COMPREHENSIVENESS
financial transactions are reflected in the OAG’s overall
review and opinion related to the BC Public Accounts, 2.1 Insured Hospital Services
which can be found at the following website link: http:// The Hospital Act and Hospital Act Regulation provide
www.fin.gov.bc.ca/iaas/Audit_Reports.htm. authority for the Minister to designate facilities as
hospitals, to license private residential care hospitals,
The OAG’s special audits and reports can be located at to approve the bylaws of hospitals, to inspect hospitals,
the following link: www.bcauditor.com/pubs. and to appoint a public administrator. This legislation
also establishes broad parameters for the operation
1.4 Designated Agency
of hospitals.
Since 2005, the Ministry has contracted with MAXIMUS
Canada to deliver the operations of MSP and PharmaCare The Hospital Insurance Act and the Hospital Insurance
(including responding to public inquiries, registering cli- Act Regulations provide the authority for the Minister to
ents, and processing medical and pharmaceutical claims make payments to health authorities for the purpose of
from health professionals). MAXIMUS Canada adminis- operating hospitals, outlines who is entitled to receive
ters the province’s medical and drug insurance plans insured services, and defines the “general hospital
under the Health Insurance BC (HIBC) program. Policy services” which are to be provided as benefits.
and decision-making functions remain with the Ministry.
Hospital services are insured when they are provided
HIBC submits monthly reports to the Ministry, report- to a beneficiary in a publicly funded hospital. There is
ing performance on service levels to the public and no scheduled or regular process to review insured hos-
healthcare providers. HIBC also posts reports on its pital services as the insured services included in the
website on the performance of key service levels. These Regulations are intended to be inclusive. Uninsured ser-
reports are available at: www2.gov.bc.ca/gov/content/ vices are referred to in section 2.4 of this report.
health/about-bc-s-health-care-system/partners/health-
insurance-bc.
106
When medically required, the following are provided to The services are provided to beneficiaries without charge,
beneficiaries who are in-patients in an acute or rehabili- with a few exceptions. Exceptions include: incremental
tation hospital: charges for preferred (but not medically required) medical/
surgical supplies and nonstandard accommodation (when
• accommodation and meals at the standard level; not medically required and standard accommodation is
available), and daily fees for residential care patients in
• necessary nursing service;
extended care or general hospitals.
• drugs, biologicals, and related preparations which are
Some facilities providing residential care services (in this
required by the patient and administered in hospital;
case, the term “extended care” is often used) are regulated
•
laboratory and radiological procedures and related under the Hospital Act. Health authorities and hospital
interpretations; societies are required to follow Home and Community
Care policies to determine benefits in such cases.
•
diagnostic procedures and the necessary interpreta-
tions, as approved by the Minister; 2.2 Insured Physician Services
The range of insured physician services covered by
•
use of operating rooms, case rooms, anaesthetic the Medical Services Plan (MSP) includes all medically
facilities, routine surgical supplies, and other neces- necessary diagnostic and treatment services. Insured
sary equipment and supplies; physician services are provided under the MPA. Section
13 provides that practitioners, including physicians and
• use of radiotherapy facilities; healthcare professionals such as midwives, who are
• use of physiotherapy facilities; enrolled with MSP and who render benefits to a
beneficiary, are eligible to be paid for services rendered
• services of a social worker; in accordance with the appropriate payment schedule.
• other rehabilitation services, including occupational and Unless specifically excluded, the following medical
speech therapy; and services are insured as MSP benefits under the MPA in
accordance with the Canada Health Act:
• other required services approved by the Minister, provided
by persons who receive remuneration from the hospital. • medically required services provided to beneficiaries
(residents of British Columbia who are enrolled in
When medically required, the following are provided MSP in accordance with section 7 of the MPA) by a
as benefits under the Hospital Insurance Act or the physician enrolled with MSP;
Medicare Protection Act (MPA) to out-patients who are
beneficiaries: • Medically required services performed in an approved
diagnostic facility under the supervision of an enrolled
• emergency department services; physician; and
• diagnostic services; • Medically required services performed in an approved
laboratory facility. These services were insured under
• use of operating room facilities;
the MPA until October 1, 2015 at which time the LSA
• equipment and supplies used in medically necessary was implemented and these services became insured
services provided to the beneficiary, including anaes- under the LSA.
thetics, sterile supplies, dressings, casts, splints,
To practice in British Columbia, physicians must be
immobilizers, and bandages;
registered and in good standing with the College of
• meals required during diagnosis and treatment; Physicians and Surgeons of British Columbia. To receive
payment for insured services, they must be enrolled
•
drugs and medications administered in a medically with MSP. In the fiscal year 2015–2016, 10,705 physi-
necessary service provided to the beneficiary; and cians were enrolled with MSP and received payments
through fee-for-service (FFS). In addition, some physi-
• any service provided by an employee of the hospital cians practice solely on salary, receive sessional
that is approved by the Minister. payments, or are on contract (service agreements) with

the health authorities. Physicians paid by these alterna- talization is medically required for the safe and proper
tive mechanisms may also practice on a FFS basis. completion of surgical-dental services. In such cases, the
surgical-dental component is covered if the service is
Practitioners other than physicians and dentists who may listed in the Dental Payment Schedule and the hospital-
enroll and provide benefits under MSP include midwives, ization component is funded by the health authority.
optometrists and supplementary benefit practitioners.
The Supplementary Benefits Program assists premium Included as insured surgical-dental procedures are those
assistance beneficiaries (see section 3.3 of this report) related to remedying a disorder of the oral cavity or a
to access the following services: acupuncture, massage functional component of mastication. Generally this would
therapy, physiotherapy, chiropractic, naturopathy, and include oral surgery related to trauma, orthognathic
podiatry (non-surgical services). The program contrib- surgery, medically required extractions, and surgical
utes $23.00 towards the cost of each patient visit to a treatment of temporomandibular joint dysfunction.
maximum of ten visits per patient per annum summed Additions or changes to the list of insured services are
across the six types of providers. managed by MSP on the advice of the Dental Liaison
Committee. Additions and changes must be approved
Physicians enrolled in MSP may choose to be opted-in or by the MSC.
opted-out. Opted-in physicians are physicians who are
enrolled in MSP under section 13 of the MPA and who Any general dental and/or oral surgeon who is in good
elect to bill MSP directly for insured services provided to standing with the College of Dental Surgeons, is enrolled
MSP beneficiaries. An opted-in physician may not bill a in MSP, and has hospital privileges, may provide insured
patient directly for an insured benefit. Opted-out physi- surgical-dental services in hospital. There were 207
cians are physicians who are enrolled in MSP under dentists enrolled with MSP in 2015–2016 (includes only
section 13 of the MPA and who elect to opt out and bill paediatric dentists, oral surgeons, dental surgeons, oral
patients directly for insured benefits. Physicians wishing medicine, and orthodontist billing through FFS). In 2015,
to opt out of MSP must give written notice to the Medical it was clarified that dental services provided in surgical
Services Commission (MSC). In this case, patients may facilities under contract with a health authority are
apply to MSP for reimbursement of the fee for insured benefits under MSP.
services rendered. By law, an opted-out physician may
not charge a patient more for an insured benefit than the 2.4 Uninsured Hospital, Physician and
prescribed MSP fee amount. In 2015–2016, MSP has two Surgical-Dental Services
opted-out physicians. Based on reclassification of infor- Medical necessity, as determined in part by the attend-
mation and corresponding data, British Columbia does ing physician, midwife, nurse practitioner, or oral and
not track non-participating physicians. maxillofacial surgeon and hospital, is the criterion for
public funding of available hospital and medical services.
Under the Physician Master Agreement between the
government, the MSC and Doctors of BC, modifications In-patient and out-patient take-home drugs and any drugs
to the MSC Payment Schedule such as additions, deletions not clinically approved by the hospital are excluded from
or fee changes are made by the MSC upon advice from coverage.
Doctors of BC or the government. To modify the payment
Procedures not insured under the Hospital Insurance Act
schedule, parties must submit proposals to the Doctors
and its Regulations include: services of medical personnel
of BC Tariff Committee. On recommendation of the Tariff
not employed or contracted by the hospital; treatment for
Committee, interim listings may be designated by the
which WorkSafeBC, the Department of Veterans Affairs
MSC for new procedures or other services for a limited
or any other agency is responsible; services or treatment
period of time while definitive listings are established.
that the Minister (or a person designated by the Minister)
During fiscal year 2015–2016, 13 physician services determines, on a review of the medical evidence, that
were added as MSP insured benefits to reflect current the beneficiary does not require; and excluded illnesses
practice standards including, for example, the introduc- or conditions (i.e. in vitro fertilization, cosmetic service
tion of arytenoid adduction. solely for the alteration of appearance; and reversal of
previous sterilization procedures except when sterilization
2.3 Insured Surgical-Dental Services was originally caused by trauma). Uninsured hospital
In certain circumstances, in-patient or out-patient hospi- services also include: preferred accommodation at the
108
patient’s request when not medically required; preferred • makes his or her home in British Columbia, and is phys-
medical/surgical supplies/devices; televisions, telephones, ically present in British Columbia for at least six months
and private nursing services; and dental care that could in a calendar year, or for a prescribed shorter period of
safely be provided in a dental office including prosthetic time; and
and orthodontic services. Health authorities are required
by Ministry policy to fund medically necessary transfers • is deemed under the Regulations to be a resident (does
between acute care hospitals within British Columbia, not include a tourist or visitor to British Columbia).
but patients are required to pay a user fee to partially off-
Certain other individuals, such as some holders of permits
set costs when an ambulance or contracted alternative
issued under the federal Immigration and Refugee
service provider is used for transport in other situations.
Protection Act are deemed to be residents (see section
Services not insured under MSP include: those covered 3.2 of this report), but this does not include a tourist or
by the Workers’ Compensation Act or by other federal or visitor to British Columbia.
provincial legislation; provision of non-implanted prosthe-
In 2014–2015, the Medical and Health Care Services
ses; orthotic devices; proprietary or patent medicines;
Regulation was amended to clarify the terms upon which
any medical examinations that are not medically required;
a resident of British Columbia may be absent from the
oral surgery rendered in a dentist’s office; telephone
province due to vacation or work and remain a beneficiary
advice unrelated to insured visits; reversal of sterilization
who qualifies for healthcare benefits.
procedures; in vitro fertilization; medico-legal services;
and most cosmetic surgeries. New residents or persons re-establishing residence in
British Columbia must be physically present in British
The MPA (section 45) prohibits the sale or issuance
Columbia for at least six months prior to being absent for
of health insurance by private insurers to patients for
more than six months. If absences exceed six months
services that would be an insured benefit. Section 17
prior to the individual being physically present for at least
prohibits persons from being charged for a benefit or
six months, residence is not established and medical
for “materials, consultations, procedures, and use of an
coverage is canceled as of the initial enrolment date.
office, clinic or other place or for any other matters that
relate to the rendering of a benefit.” All residents are entitled to hospital and medical care in-
surance coverage. Those residents who are members of
The Ministry responds to complaints made by patients
the Canadian Forces and those serving a term of impris-
and takes appropriate actions to correct situations
onment in a penitentiary as defined in the Corrections
identified to the Ministry. The MSC determines which
and Conditional Release Act, are eligible for federally
services are benefits and has the authority to de-insure
funded health insurance. The Medical Services Plan (MSP)
insured services. Proposals to de-insure services must be
provides first-day coverage to discharged members of the
made to the MSC. Consultation may take place through a
Canadian Forces and to those returning from an overseas
sub-committee of the MSC and usually includes a review
tour of duty, as well as to released inmates of federal
by Doctors of BC’s Tariff Committee.
penitentiaries.
The number of residents registered with MSP as of

3.0 UNIVERSALITY March 31, 2016 was 4,746,685.
3.1 Eligibility 3.2 Other Categories of Individuals
Section 7 of the Medicare Protection Act (MPA) defines Some holders of Minister’s Permits, Temporary Resident
the eligibility and enrolment of beneficiaries for insured Permits, study permits, work permits and applicants for
services. Under the MPA, Part 2 of the Medical and Health permanent resident status who are the spouse or child
Care Services Regulation details residency requirements. of an eligible resident may be eligible for benefits when
A person must be a resident of British Columbia to qualify deemed to be residents under the MPA and section 2 of
for provincial healthcare benefits. the Medical and Health Care Services Regulation.
Section 1 of the MPA defines a resident as a 3.3 Premiums
person who: The legislation enabling the collection of premiums is:
• is a citizen of Canada or is lawfully admitted to Canada • Medicare Protection Act, Part 2 — Beneficiaries section
for permanent residence; 8; and

• Medical and Health Care Services Regulation, Part 3— their home in British Columbia in order to retain cover-
Premiums. age. As of January 1, 2013, longer term vacationers who
are deemed residents may qualify for a total absence
Enrolment in MSP is mandatory and payment of premi- of up to seven months per calendar year for vacation
ums is ordinarily a requirement for coverage. However, purposes only, provided they continue to maintain their
failure to pay premiums is not a barrier to coverage for home in British Columbia.
those who meet the basic enrolment eligibility criteria.
MSP monthly premium rates effective January 1, 2016, Individuals leaving the province temporarily on extended
are $75.00 for one person, $136.00 for a family of two, vacations, or for temporary employment, may be eligible
and $150.00 for a family of three or more. to retain their medical coverage for up to 24
consecutive months provided that they are physically
MSP has two programs that offer assistance with the present in BC for six of the 12 months immediately
payment of premiums based on financial need. Regular preceding departure. Approval is limited to once in five
premium assistance has five levels of assistance and years for absences exceeding six months in a calendar
is based on a person’s net income for the preceding year. When a beneficiary stays outside British Columbia
tax year, combined with that of the person’s spouse, if longer than the approved period, they will be required to
applicable, less MSP deductions. fulfill a waiting period upon re-establishing residence in
the province before coverage can be renewed. Students
A short term, 100 per cent subsidy is offered under
attending a recognized school in another province or
the temporary premium assistance program based on
territory on a full-time basis are entitled to coverage for
current, unexpected financial hardship. Premium assis-
the duration of their studies, provided that they return to
tance is available only to beneficiaries who, for the last
BC to re-establish their residency by the last day of the
12 consecutive months, have resided in Canada and
month following the month in which their studies end.
are either a Canadian citizen or a holder of permanent
resident (landed immigrant) status under the federal According to inter-provincial/territorial reciprocal billing
Immigration and Refugee Protection Act. arrangements, physicians, except in Quebec, bill their
own medical plans directly for services rendered to
British Columbia residents who are eligible for the
4.0 PORTABILITY Medical Services Plan (MSP), upon presentation of a
4.1 Minimum Waiting Period valid CareCard or BC Services Card. British Columbia
New residents or persons re-establishing residence in then reimburses the province or territory at the rate of
British Columbia are eligible for coverage after completing the fee schedule in the province or territory in which
a waiting period that normally consists of the balance of services were rendered. For in-patient hospital care,
the month residence is established plus two additional services are paid at the ward rate approved for each hos-
months. For example, if an eligible person arrives during pital by the Assistant Deputy Ministers Policy Advisory
the month of July, coverage is available October 1. If ab- Committee. For out-patient services, the payment is
sences from Canada exceed a total of 30 days during the at the inter-provincial/territorial reciprocal billing rate.
waiting period, eligibility for coverage may be affected. Payment for these services, except for excluded services
New residents from other parts of Canada are advised that are billed to the patient, is handled through inter-
to maintain coverage with their former medical plan provincial/territorial reciprocal billing procedures.
during the waiting period. Quebec does not participate in reciprocal billing agree-
4.2 Coverage During Temporary Absences in Canada ments for physician services. As a result, claims for
Sections 3, 4 and 5 of the Medical and Health Care services provided to British Columbia beneficiaries
Services Regulation define portability provisions for by Quebec physicians must be handled individually.
persons temporarily absent from British Columbia When travelling in Quebec (or outside of Canada) the
with regard to insured services. beneficiary is usually required to pay for medical services
and seek reimbursement later from MSP.
Residents who spend part of every year outside British
Columbia must be physically present in Canada at least British Columbia pays host provincial rates for insured ser-
six months in a calendar year and continue to maintain vices according to rates established by the Interprovincial
Health Insurance Agreements Coordinating Committee.
110
4.3 Coverage During Temporary Absences for up to an additional 12 months if they are visiting in
Outside Canada Canada or abroad. This also applies to the person’s spouse
The provisions that define portability of health insurance and children provided they are with the person and they
during temporary absences outside Canada are stated are also residents or deemed residents.
in the Hospital Insurance Act, section 24; the Hospital
Insurance Act Regulations, Division 6; the Medicare British Columbia residents who are eligible for coverage
Protection Act, section 51; and the Medical and Health while temporarily absent from British Columbia may
Care Service Regulation, sections 3, 4, and 5. receive reimbursement from MSP for out-of-country
medical expenses. MSP provides coverage for out-of-
Residents who leave British Columbia temporarily to country emergency physician services up to the British
attend school or university are eligible for MSP cover- Columbia physician fee rates. Reimbursement for out-
age for the duration of their studies provided they were of-country emergency hospital services is limited to a
physically present in Canada for six of the 12 months maximum benefit of $75.00 per day. Any excess cost is
immediately preceding departure, and are in full- the responsibility of the beneficiary. Reimbursements
time attendance at a recognized educational facility. are made in Canadian dollars.
Beneficiaries who have been studying outside British
Columbia must return to the province by the end of 4.4 Prior Approval Requirement
the month following the month in which studies are No prior approval is required for medically required pro-
completed. Any student who will not return to British cedures that are covered under interprovincial reciprocal
Columbia within that timeframe should contact MSP. agreements with other provinces. Prior approval from the
MSC is required for procedures that are excluded under
Residents who spend part of every year outside British the reciprocal agreements.
Columbia must be physically present in Canada at least
six months in a calendar year and continue to maintain The physician services excluded under the Interprovincial
their home in British Columbia in order to retain coverage. Agreements for the Reciprocal Processing of Out-of-
As of January 1, 2013, longer term vacationers who are Province Medical Claims are: surgery for alteration of
deemed residents may qualify for a total absence of up appearance (cosmetic surgery); gender reassignment
to seven months per calendar year for vacation purposes. surgery; surgery for reversal of sterilization; routine
periodic health examinations including routine eye exam-
In some circumstances, while temporarily outside the inations; in vitro fertilization, artificial insemination; acu-
province for work or vacation, an individual may be puncture, acupressure, transcutaneous electro-nerve
deemed an eligible resident during an ‘extended stimulation, moxibustion, biofeedback, hypnotherapy;
absence’ of up to 24 consecutive months once in a five- services to persons covered by other agencies (e.g.,
year period. To qualify, he or she must obtain prior approval Canadian Armed Forces, Workers’ Compensation Board,
for status as a resident during the absence, continue to Department of Veterans Affairs, Correctional Services
maintain their home in British Columbia, be physically of Canada); services requested by a third party; team
present in Canada for six of the 12 months immediately conferences; genetic screening and other genetic inves-
preceding departure and have not been granted an tigation, including DNA probes; procedures still in the
extended absence in the previous five calendar years. In experimental/developmental phase; and anaesthetic
addition, they must not have taken advantage of the services and surgical assistant services associated with
additional one month absence available to vacationers all of the foregoing.
during the year the extended absence begins, or during
the calendar year prior to the start of the extended The services on this list may or may not be reimbursed by
absence. In certain situations, if a person’s employment the home province. The patient should make inquiries of
requires them to routinely travel outside of British that home province either before receiving treatment by
Columbia for more than six months per calendar year, a British Columbia physician or after direct payment to the
they can apply to the Medical Services Commission British Columbia physician. Some treatments (e.g., treat-
(MSC) for approval to maintain their eligibility. ment services in not-for-profit residential facilities) may
require the recommendation of the Ministry of Health.
British Columbia residents who are temporarily absent
from British Columbia and cannot return due to exten- All non-emergency procedures performed outside
uating health circumstances may be deemed residents Canada require approval from the MSC before the

procedure in order to be eligible for reimbursement health infrastructure is maintained and renewed within
under MSP. All such applications for reimbursement are expected asset lifecycle timelines.
considered on a case by case basis.
The PMA is a formal agreement signed by the Government
5.0 ACCESSIBILITY of British Columbia, BC Medical Association (the Doctors
5.1 Access to Insured Health Services of BC), and the Medical Services Commission (MSC).
Beneficiaries in British Columbia, as defined in section 1 In December 2014, doctors in British Columbia voted in
of the Medicare Protection Act (MPA), are eligible for all favour of a new agreement with government. The new
insured hospital and medical care services as required. five-year agreement (term April 1, 2014 to March 31,
To ensure equal access to all, regardless of income, 2019) supports ongoing efforts to recruit and retain phy-
the MPA, sections 17 and 18, prohibits extra-billing by sicians while also improving access to specialists and
enrolled practitioners. care in rural and remote communities.
Access to insured services continues to The PMA gives the Doctors of BC the exclusive right to
be enhanced: represent the interests of all physicians who receive
• The Alternative Payments Program funds regional health payment for the medical services they provide to
authorities to contract with or hire general practitioners persons insured through MSP. The PMA establishes
(GPs) and/or specialists in order to deliver insured mechanisms which promote enhanced collaboration
clinical services. and accountabilities between the province and Doctors
of BC through various joint committees. It also pro-
•
The Full-Service Family Practice Incentive Program vides a formal conflict management process at both the
continues to be expanded as the Ministry of Health local and provincial levels and language limiting
(the Ministry) and physicians continue to work together physician service withdrawals. The role of health
to develop incentives aimed at helping to support and authorities in the planning and delivery of healthcare
sustain full-service family practice. services are reinforced in the PMA.
• The Ministry provides funding through the Medical On- The PMA establishes the compensation and benefit
Call Availability Program to health authorities to enable structure for physicians who provide publicly funded
them to contract with groups of physicians to provide medical services whether on fee-for-service or alter-
“on-call” coverage necessary for hospitals to deliver nate funding methods (service contracts, salaries, and
emergency healthcare services to unassigned patients sessional arrangements). Through the PMA, the province
in a reliable, effective, and efficient manner. also provides targeted financial support for areas such as:
rural physician incentive programs; access to specialist
•
The Ministry continued and implemented several services; supporting full service family practices; and
programs under the 2012 Rural Practice Subsidiary shared care models involving GPs, specialists, and other
Agreement, which were continued in the Physician healthcare professions.
Master Agreement (PMA) to enhance the availability
and stability of physician services in smaller urban, ru- Physicians are licensed under the Health Professions
ral, and remote areas of British Columbia. An outline of Act. The agreement provides processes for monitoring
these programs can be obtained at: www.health.gov. and managing the funding established by the MSC under
bc.ca/pcb/rural.html. section 25 of the MPA for insured medical services
provided by physicians on a fee-for-service basis. Mech-
Infrastructure and Capital Planning anisms for revisions to the Payment Schedule and for
the payment of physicians are detailed in the PMA.
British Columbia continues to make strategic invest-
ments in health sector capital infrastructure. The Ministry Dentists are licensed under the Health Professions Act.
invests annually to renew and extend the asset life of The province and the British Columbia Dental Association
existing health facilities, medical and diagnostic equip- (BCDA) have entered into a Dentistry Master Agreement
ment, and information management technology at for the period April 1, 2014 to March 31, 2019 that covers
numerous health facilities across British Columbia. The the following services: dental surgery; oral surgery;
Ministry has developed a ten year capital plan to ensure orthodontic services; oral medicine; paediatric dental
112
services; and dental technical procedures. Both the provide operating budgets to hospitals within their
province and the BCDA meet through a Dentistry Liaison control to deliver specified services. The exception
Committee for the duration of the agreement. to this is when funding provided to health authorities
(again not directly to hospitals) is targeted for specific
Compensation Methods for Physicians and Dentists priority projects (e.g., reduction in wait times for specific
procedures). Since it is specifically targeted, it must be
Payment for medical services delivered in the province is reported on separately.
made through MSP to individual physicians, based on
submitted claims, and through the Alternative Annual incremental funding is allocated to health
Payment Program to health authorities for physician time authorities using the Ministry’s Population Needs-Based
spent providing services to patients. The government Funding Formula and other funding allocation methodol-
funds health authorities to enter into alternative payment ogies (targeted funding allocations directed to specific
arrangements with other physicians; it typically does not health authorities e.g., for wage costs related to collective
pay physicians directly. In British Columbia, MSP only bargaining). The annual funding allocation to health
pays for medically required dental services and medically authorities does not include funding for programs directly
required dental surgical services performed in a hospital. operated by the Ministry, such as payments to physicians
through the Medical Services Plan and payments for
5.3 Payments to Hospitals prescription drugs covered under PharmaCare.
Funding for insured hospital services are included within
annual funding allocations to health authorities, as well The accountability mechanisms associated with govern-
as specifically targeted funding from time to time. This ment funding for hospitals is part of several comprehen-
funding allocation is used to fund the full range of sive documents which set expectations for health
necessary health services for the population of the authorities. These are the annual funding letter, annual
region (or for specific provincial services, for the service plans, mandate letters, and annual bi-lateral
population of British Columbia), including the provision agreements. Taken together, these documents convey
of hospital services. Annual funding allocations to health the Ministry’s broad expectations for health authorities
authorities are determined as part of the Ministry’s and explain how performance will be monitored in relation
annual budget process in consultation with the Ministry to these expectations.
of Finance and Treasury Board. The final funding amount
is conveyed to health authorities by means of an annual
funding letter. 6.0 RECOGNITION GIVEN TO
The Hospital Insurance Act and its related Regulations FEDERAL TRANSFERS
and the Health Authorities Act govern payments made Funding provided by the federal government through
by government to health authorities. These statutes es- the Canada Health Transfer is recognized and reported
tablish the authority of the Minister of Health to make by the Government of British Columbia through various
payments to regional health authorities and the Provincial government websites and provincial government docu-
Health Services Authority and specify in broad terms ments. In 2015–2016, these documents included:
what services are insured when provided within a hospital
and in delivering regional and other healthcare services. • Estimates, Fiscal Year Ending March 31, 2016, available
at: http://bcbudget.gov.bc.ca/2015/estimates/2015_
The British Columbia Tripartite Framework Agreement Estimates.pdf.
on First Nation Health Governance and other negotiated
agreements, provide the basis for the Ministry of Health •
Budget and Fiscal Plan 2015–2016 to 2017–2018,
to provide funding to the First Nations Health Authority. available at: http://bcbudget.gov.bc.ca/2015/bfp/2015_
Funding to support the Nisga’a Nation health care budget_and_fiscal_plan.pdf.
services and programs is provided to the Nisga’a Valley
Health Authority under the terms of the 1999 Nisga’s • Public Accounts 2015–2016, available at: http://www.
Valley Health Board Transitional Funding Agreement. fin.gov.bc.ca/ocg/pa/15_16/Public%20Accounts.pdf.
The Ministry does not specifically fund hospitals

directly; instead health authorities are funded and

REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 1 120 120 120 120 120
Payments for insured health services ($) 2
not available not available not available not available not available

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of private for-profit facilities not available not available not available not available not available
Payments to private for-profit facilities not available not available not available not available not available

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
1 As per the guidelines, the number of public facilities in this table excludes psychiatric hospitals and extended care facilities.
2 BC Ministry of Health Funding to Health Authorities for the provision of the full range of regionally delivered services are as follows:
$9.2 billion in 2010–2011, $9.7 billion in 2011–2012, $10.1 billion in 2012–2013, $10.5 billion in 2013-2014, and $10.8 billion in 2014–2015.
114

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
physicians (#) 3
physicians (#)
Number of non-participating not available not available not available not available not available
physicians (#)

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 32,453,109 32,502,933 33,860,748 37,002,462 335,593,832

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 4,869,497 4,340,034 4,148,174 4,091,804 3,164,525

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 8,130,009 7,903,742 8,456,773 8,417,735 8,232,622
3 The number of participating physicians in item 14 is for physicians who received payments through fee-for-service.

CHAPTER 3 | YUKON
YUKO N
The Yukon Health Care System is committed to (YHCIP) and the Yukon Hospital Insurance Services Plan
ensuring that residents of the Yukon acquire the (YHISP). Both the YHCIP and YHISP are administered
by the Director, Insured Health and Hearing Services.
skills to live responsible, healthy and independent
This position is a joint appointment by the Minister of
lives. The Minister of Health and Social Services Health and Social Services and the Commissioner of the
is responsible for delivering all insured health Yukon Territory.
care services with service delivery administered
The Health Care Insurance Plan Act, section 3(2) and
centrally by the Department of Health and Social
section 4, establishes the public authority to operate the
Services (DHSS). health care plan.
The Health Services Division of DHSS is The Hospital Insurance Services Act, section 3(1) and
responsible for a variety of health care, disease section 5, establishes the public authority to operate the
prevention and treatment services which assist hospital care plan.
eligible Yukon residents in attaining maximum Subject to the Health Care Insurance Plan Act (section
individual independence within their community. 5), the Hospital Insurance Services Act (section 6) and
Health Services oversees Community Health the Regulations, it is the responsibility of the Director,
Services, Community Nursing, Communicable Insured Health and Hearing Services to:
Disease Control, Health Promotion, Dental • administer both plans;
Health, Environmental Health and Mental
• determine eligibility for insured health services;
Health Services.
• establish advisory committees and appoint individuals
In 2015-2016 DHSS continued to focus on the col- to advise or assist in the operation of the plans;
laborative care approach for patient care to ensure
•
determine the amounts payable for insured health
better and more cost effective services to residents
services outside the Yukon;
of Yukon. In 2015-2016 this included securing per-
manent funding for the Weight Wise Program and • conduct surveys and research programs, and obtain
continued support for the Referred Care, Women’s statistics for such purposes;
MidLife Health and Reproductive Health Clinics. •
appoint inspectors and auditors to examine and
obtain information from medical records, reports, and
accounts; and
1.0 PUBLIC ADMINISTRATION • perform any other functions and discharge any other
duties assigned by the Minister of Health and Social
1.1 Health Care Insurance Plan and Public Authority Services under the Act.
The Insured Health and Hearing Services Branch (IHS)
is responsible for the delivery of health care benefits Specific to the Hospital Insurance Services Act, the
as set out in the Health Care Insurance Plan Act and Director, Insured Health and Hearing Services has the
Hospital Insurance Services Act. The overall objective responsibility to:
of the IHS is to ensure access to, and portability of,
• enter into agreements on behalf of the Government
insured physician and hospital services according to the
of Yukon with hospitals in or outside of Yukon, or with
provisions of these acts.
the Government of Canada or any province or an ap-
The Government of Yukon delivers insured health ben- propriate agency thereof, for the provision of insured
efits according to the Yukon Health Care Insurance Plan services to insured persons;
116
CHAPTER 3 | YUKON
• prescribe the forms and records necessary to carry include the financial statements of the Corporation and
out the provisions of the Act; and the Auditor’s report.
• perform any other functions and discharge any other du-

ties assigned to the administrator by the Regulations. 2.0 COMPREHENSIVENESS
There were no amendments to either Act in 2015–2016. 2.1 Insured Hospital Services
The Hospital Insurance Services Act, sections 3, 4, 5, 6
and 9, establish authority to provide insured hospital ser-
The Department of Health and Social Services is account-
vices to insured residents. The Yukon Hospital Insurance
able to the Legislative Assembly and the Government of
Services Ordinance was first passed in 1960 and came
Yukon through the Minister.
into effect April 9, 1960. No amendments were made to
Section 6 of the Health Care Insurance Plan Act and sec- the Act in 2015–2016.
tion 7 of the Hospital Insurance Services Act require
Adopted on December 7, 1989, the Hospital Act
that the Director, Insured Health and Hearing Services
establishes the responsibility of the legislature and the
make an annual report to the Minister of Health and
government to ensure “compliance with appropriate
Social Services respecting the administration of the two
methods of operation and standards of facilities and
health insurance plans. A Statement of Revenue and
care.” Adopted on November 11, 1994, the annexed
Expenditures is tabled in the legislature and is subject to
Hospital Standards Regulation sets out the conditions
discussion at that level. The Statement of Revenue and
under which all hospitals in the territory are to operate.
Expenditures will be tabled in the fall 2016 sitting of the
Section 4(1) provides for the Ministerial appointment of
Yukon legislature.
one or more investigators to report on the management
1.3 Audit of Accounts and administration of a hospital. Section 4(2) requires
The Health Care Insurance Plan and the Hospital Insur- that the hospital’s Board of Trustees establish and main-
ance Services Plan are subject to audit by the Office tain a quality assurance program.
of the Auditor General of Canada. The Auditor General
In April 1997, the Yukon Government assumed responsi-
of Canada is the Auditor of the Government of Yukon in
bility for operating health units in rural Yukon communities
accordance with section 34 of the Yukon Act (Canada).
from the federal government. These health centres are
The Auditor General is required to conduct an annual
staffed by one or more nurses and auxiliary staff. Primary
audit of the transactions and consolidated financial
Health Care Nurses in the absence of a physician, provide
statements of the Government of Yukon. Further, the
daily clinics for medical treatment, community health
Auditor General of Canada is to report to the Yukon
programs and 24-hour emergency services in 11 commu-
Legislative Assembly any matter falling within the scope
nities throughout Yukon along with the Whitehorse Health
of the audit that, in his or her opinion, should be reported
Centre which offers immunization clinics and pre- and
to the Assembly.
postnatal care.
In 2013, the Office of the Auditor General of Canada
In 2015–2016, insured in-patient and out-patient hos-
released the 2013 Report of the Auditor General of
pital services were delivered in 15 facilities throughout
Canada, Capital Projects — Yukon Hospital Corporation.
the territory. These facilities include Whitehorse General
Since that time there were no reports related to the
Hospital, Watson Lake Community Hospital, Dawson City
Department of Health and Social Services released by
Community Hospital and 12 Community Health Centres.
the Office of the Auditor General of Canada.
The Yukon Hospital Corporation completed their
Further, section 13(2) of the Hospital Act requires the
accreditation process in May 2014 as part of a four-
Yukon Hospital Corporation to submit a report of their
year cycle through Accreditation Canada. Whitehorse
operations for that fiscal year to the Minister within six
General Hospital and Watson Lake Community Hospital
months after the end of each fiscal year. The report is to

CHAPTER 3 | YUKON
took part in this process, while Dawson City Community representation regarding changes in service levels is
Hospital will take part in the next process in 2018. made through membership on the hospital board.
Pursuant to the Hospital Insurance Services Regulations, In October 2015, DHSS started work on implementing
section 2(e) and (f), services provided in an approved the Health Information Privacy and Management Act
hospital are insured. Section 2(e) defines in-patient Regulations. The Act balances protection of personal
insured services as all of the following services to in- health information with the information needs of health
patients, namely: accommodation and meals at the care workers so that they can provide Yukoners with
standard or public ward level; necessary nursing service; the best care possible. Regulations for the Act will set
laboratory, radiological and other diagnostic procedures out standards for how personal health information is
together with the necessary interpretations for the pur- secured and what professions or organizations the Act
pose of maintaining health, preventing disease and will apply to.
assisting in the diagnosis and treatment of an injury,
illness or disability; drugs, biologicals and related prepa- 2.2 Insured Physician Services
rations as provided in Schedule B of the Regulations, Insured physician services in Yukon are defined as medi-
when administered in the hospital; use of operating cally required services rendered by a medical practitioner.
room, case room and anaesthetic facilities, including Sections 1 to 8 of the Health Care Insurance Plan Act and
necessary equipment and supplies; routine surgical sections 2, 3, 7, 10 and 13 of the Health Care Insurance
supplies; use of radiotherapy facilities where available; Plan Regulations provide for insured physician services.
use of physiotherapy facilities where available; and ser- No amendments were made to the Act in 2015–2016.
vices rendered by persons who receive remuneration
The Yukon Health Care Insurance Plan covers physicians
from the hospital.
providing medically required services. In order to
Section 2(f) of the Regulations defines “out-patient participate in the Yukon Health Care Insurance Plan,
insured services” as all of the following services to physicians must:
out-patients, when used for emergency diagnosis or
• register for licensure pursuant to the Health Professions
treatment within 24 hours of an accident (period may be
Act; and
extended by the Administrator, provided the service could
not be obtained within 24 hours of the accident): neces- • maintain licensure, pursuant to the Health Professions
sary nursing service; laboratory, radiological and other Act.
procedures, together with the necessary interpretations
for the purpose of assisting in the diagnosis and treatment The number of resident physicians participating in the
of an injury; drugs, biologicals and related preparations Yukon Health Care Insurance Plan in 2015–2016 was 78,
as provided in Schedule B, when administered in a hos- along with 49 locums and 56 visiting specialists.
pital; use of operating room and anaesthetic facilities,
Section 7 of the Yukon Health Care Insurance Plan
including necessary equipment and supplies; routine
Regulations covers payment for medical services.
surgical supplies; services rendered by persons who
Subsection 4 allows physicians to make arrangements
receive remuneration therefor from the hospital; use
for payment for insured services on a basis other than
of radiotherapy facilities where available; and use of
fee-for-service. Notice in writing of this election must be
physiotherapy facilities where available.
submitted to the Director, Insured Health and Hearing
Pursuant to the Hospital Insurance Services Regulations, Services. In 2015-2016, physicians were remunerated
all in-patient and out-patient services provided in an via both the fee-for-service model and alternative pay-
approved hospital, by hospital employees, are insured ment arrangements. The process used to add a new
services. Standard nursing care, pharmaceuticals, sup- fee to the Payment Schedule for Yukon is administered
plies, diagnostic and operating services are provided. through a committee structure. This process requires
Any new programs or enhancements with significant physicians to submit requests in writing to the Yukon
funding implications or reductions to services or pro- Health Care Insurance Plan, Yukon Medical Association
grams require the prior approval of the Minister, Health Liaison Committee. Following review by this committee,
and Social Services. This process is managed by the a decision is made to include or exclude the service. The
Director, Insured Health and Hearing Services. Public relevant costs or fees are normally set in accordance
118
CHAPTER 3 | YUKON
with similar costs or fees in other jurisdictions. Once a Section 3 of the Yukon Health Care Insurance Plan
fee-for-service value has been determined, notification Regulations contains a list of services that are pre-
of the service and the applicable fee is provided to all scribed as non-insured. Uninsured physician services
Yukon physicians. Public consultation is not required. include: advice by telephone; medical-legal services;
testimony in court; preparation of records, reports, cer-
Alternatively, new fees can be implemented as a tificates and communications; services or examinations
result of the fee negotiation process between the Yukon required by a third party; services, examinations or
Medical Association and the Department of Health reports for reasons of attending university or camp;
and Social Services. The Director, Insured Health and examination or immunization for the purpose of travel,
Hearing Services manages this process and no public employment or emigration; cosmetic services; services
consultation is required. not medically required; giving or writing prescriptions;
the supply of drugs; dental care except procedures
2.3 Insured Surgical-Dental Services
listed in Schedule B; and experimental procedures.
Dentists providing insured surgical-dental services
under the Health Care Insurance Plan of Yukon must Physicians in Yukon may bill patients directly for non-
be licensed pursuant to the Dental Professions Act and insured services. Block fees are not used at this time;
are given billing numbers to bill the Yukon Health Care however, some do bill by service item. Billable services
Insurance Plan for providing insured dental services. The include but are not limited to: completion of employ-
Plan is also billed directly for services provided outside ment forms; medical-legal reports; transferring records;
the territory. third-party examinations; some elective services; and
telephone prescriptions, advice or counseling.
Insured dental services are limited to those surgical-
dental procedures listed in Schedule B of the Health Payment does not affect patient access to services
Care Insurance Plan Regulations. The procedures must because not all physicians or clinics bill for these services
be performed in a hospital. and other agencies or employers may cover the cost.
The addition or deletion of new surgical-dental services Uninsured dental services include procedures consid-
to the list of insured services requires amendment by ered restorative and procedures that are not performed
Order-in-Council to Schedule B of the Health Care in a hospital under general anaesthesia.
Insurance Plan Regulations. Coverage decisions are
made on the basis of whether or not the service must be All Yukon residents have equal access to services.
provided in hospital under general anaesthesia. The Third parties, such as private insurers or the Worker’s
Director, Insured Health and Hearing Services adminis- Compensation Health and Safety Board, do not receive
ters this process. priority access to services through additional payment.
The purchase of non-insured services, such as fibre-
There were no new insured surgical-dental services glass casts, does not delay or prevent access to insured
added in 2015–2016. services at any time. Insured persons are given treat-
ment options at the time of service.
Surgical-Dental Services Yukon has no formal process to monitor compliance;
Only services prescribed by and rendered in accordance however, feedback from physicians, hospital administra-
with the Health Care Insurance Plan Act and Regulations tors, medical professionals and staff allows the Director,
and the Hospital Insurance Services Act and Regulations Insured Health and Hearing Services to monitor usage
are insured. All other services are uninsured. and service concerns.
Uninsured hospital services include: non-resident The process used to de-insure services covered by the
hospital stays; special or private nurses requested by Yukon Health Insurance Plan is as follows:
the patient or family; additional charges for preferred
accommodation unless prescribed by a physician; Physician services — the Yukon Health Care Insurance
crutches and other such appliances; nursing home Plan, Yukon Medical Association Fee Liaison Committee
charges; televisions; telephones; and drugs and is responsible for reviewing changes to the Payment
biologicals following discharge. (These services are not Schedule for Yukon including decisions to de-insure
provided by the hospital). certain services. In consultation with the Yukon Medical

CHAPTER 3 | YUKON
Advisor, decisions to de-insure services are based on complete this waiting period. The only exception is for
medical evidence that indicates the service is not medi- children adopted by insured persons, and for newborns.
cally necessary, is ineffective or a potential risk to the
patient’s health. Once a decision has been made to The following persons are not eligible for coverage
de-insure a service, all physicians are notified in in Yukon:
writing. The Director, Insured Health and Hearing • persons entitled to coverage from their home prov-
Services, manages this process. No services were ince or territory (e.g., students and workers covered
removed in 2015–2016. under temporary absence provisions);
Hospital services — an amendment by Order-in-Council • visitors to Yukon;

to sections 2(e) and 2(f) of the Yukon Hospital Insurance
• refugee claimants;
Services Regulations would be required. As of March
31, 2016, no insured in-patient or out-patient hospital • convention refugees;
services, as provided for in the Regulations, have been
de-insured. The Director, Insured Health and Hearing • inmates in federal penitentiaries;
Services is responsible for managing this process in
• study permit holders, unless they are a child and they
conjunction with the Yukon Hospital Corporation.
are listed as the dependent of a person who holds a
Surgical-dental services — an amendment by Order- one year work permit; and
in-Council to Schedule B of the Health Care Insurance
• employment authorizations of less than one year.
Plan Regulations is required. A service could be de-
insured if determined not medically necessary or is no The above persons may become eligible for coverage if
longer required to be carried out in a hospital under they meet one or more of the following conditions:
general anesthesia. The Director, Insured Health
and Hearing Services manages this process. No • establish residency in Yukon;
surgical-dental services were de-insured in 2015–2016.
• become a permanent resident; or
• for inmates at the Whitehorse Correctional Centre,

3.0 UNIVERSALITY
the day following discharge or release if stationed in
3.1 Eligibility or a resident in Yukon.
Eligibility requirements for insured health services
The number of registrants in the Yukon Health Care
are set out in the Health Care Insurance Plan Act and
Insurance Plan as of March 31, 2016 was 38,831.
Regulations, sections 2 and 4, and the Hospital
Insurance Services Act and Regulations, sections 2 and 3.2 Other Categories of Individuals
4. There were no changes to the legislation in 2015–2016. The Yukon Health Care Insurance Plan provides health care
coverage for other categories of individuals, as follows:
Subject to the provisions of these acts and regulations,
every Yukon resident is eligible for and entitled to Returning Canadians: waiting period is applied
insured health services on uniform terms and
conditions. The term “resident” is defined using the Permanent Residents: waiting period is applied
wording of the Canada Health Act and means a person
lawfully entitled to be or to remain in Canada, who Minister’s Permit: waiting period is applied, if authorized
makes his or her home and is ordinarily present in
Foreign Workers: waiting period is applied, if holding
Yukon, but does not include a tourist, transient, foreign
Employment Authorization
student or visitor. Pursuant to section 4(1) of the Yukon
Health Care Insurance Plan Regulations and the Yukon Clergy: waiting period is applied, if holding Employment
Hospital Insurance Services Regulations, an insured per- Authorization
son is eligible for and entitled to insured services after
midnight on the last day of the second month following Employment Authorizations must be in excess of 12
the month of arrival to the Territory. All persons returning months.
to or establishing residency in Yukon are required to
120
CHAPTER 3 | YUKON
4.0 PORTABILITY Yukon participates fully with the Interprovincial Medical

Reciprocal Billing Agreements and Hospital Reciprocal
4.1 Minimum Waiting Period Billing Agreements in place with all other provinces and
Where applicable, the eligibility of all persons is territories with the exception of Quebec, which does not
administered in accordance with the Interprovincial participate in the medical reciprocal billing arrangement.
Agreement on Eligibility and Portability. Under section Persons receiving medical (physician) services in Quebec
4(1) of both Regulations, “an insured person is eligible may be required to pay directly and submit claims to the
for and entitled to insured services after midnight on the Yukon Health Care Insurance Plan for reimbursement.
last day of the second month following the month of
arrival to the Territory.” All persons entitled to coverage The Hospital Reciprocal Billing Agreements provide for
are required to complete the minimum waiting period payment of insured in-patient and out-patient hospital
with the exception of children adopted by insured services to eligible residents receiving insured services
persons (see section 3.1), and newborns. outside Yukon, but within Canada.
4.2 Coverage During Temporary Absences in Canada The Medical Reciprocal Billing Agreements provide for
The provisions relating to portability of health care payment of insured physician services on behalf of
insurance during temporary absences outside Yukon, eligible residents receiving insured services outside
but within Canada, are defined in sections 5, 6, 7 and Yukon, but within Canada. Payment is made to the host
10 of the Yukon Health Care Insurance Plan Regulations province at the rates established by that province.
and sections 6, 7(1), 7(2) and 9 of the Yukon Hospital
Insured services provided to Yukon residents while
Insurance Services Regulations.
temporarily absent from the territory are paid at the
The Regulations state that, “where an insured person is rates established by the host province.
absent from the Territory and intends to return, he/she is
4.3 Coverage During Temporary
entitled to insured services during a period of 12 months
Absences Outside Canada
continuous absence.” Persons leaving Yukon for a period
The provisions that define portability of health care in-
exceeding three months are advised to contact Yukon
surance to insured persons during temporary absences
Insured Health Services and complete a Temporary
outside Canada are defined in sections 5, 6, 7, 9, 10 and
Absence form. Failure to do so may result in cancellation
11 of the Yukon Health Care Insurance Plan Regulations
of coverage.
and sections 6, 7(1), 7(2) and 9 of the Yukon Hospital
Students attending educational institutions full-time Insurance Services Regulations.
outside Yukon remain eligible for the duration of their
Sections 5 and 6 currently state that, where an insured
academic studies. The Director, Insured Health and
person is absent from Yukon and intends to return, the
Hearing Services (the Director) may approve other
person is entitled to insured services during a period of
absences in excess of 12 consecutive months upon
12 months continuous absence. Similarly, to general
receiving a written request from the insured person.
temporary absences, regulatory work on coverage
Requests for extensions must be renewed yearly and
during temporary absences outside Canada is currently
are subject to approval by the Director.
underway and will receive further public input prior to
For temporary workers and missionaries, the Director enacting changes.
may approve absences in excess of 12 consecutive
Persons leaving Yukon for a period exceeding three
months upon receiving a written request from the in-
months are advised to contact Yukon Health Care
sured person. Requests for extensions must be renewed
Insurance Plan and complete a Temporary Absence form.
yearly and are subject to approval by the Director.
Failure to do so may result in cancellation of the coverage.
The provisions regarding coverage during temporary
The provisions for portability of health insurance during
absences in Canada fully comply with the terms and
out-of-country absences for students, temporary workers
conditions of the Interprovincial Agreement on Eligibility
and missionaries are the same as for absences within
and Portability effective February 1, 2001. Definitions are
Canada (see section 4.2 of this report).
consistent in regulations, policies and procedures.

CHAPTER 3 | YUKON
Insured physician services provided to eligible Yukon Additionally IHS provides extended health benefits to
residents temporarily outside the country are paid at eligible Yukon residents which include the Travel for
rates equivalent to those paid had the service been Medical Treatment Program, the Children’s Drug and
provided in Yukon. Reimbursement is made to the Optical Program, the Chronic Disease and Disability
insured person by the Yukon Health Care Insurance Plan Benefits Program, Pharmacare Program, Extended
or directly to the provider of the insured service. Benefits Program and Hearing Services Program.
Insured in-patient hospital services provided to eligible The Yukon Hospital Corporation operates the three hos-
Yukon residents outside Canada are paid at the rate pitals in the territory: Whitehorse General Hospital, WGH,
established in the Standard Ward Rates Regulation for Watson Lake Community Hospital and Dawson City
the Whitehorse General Hospital. This rate was $2,383 Community Hospital. In 2015–2016 construction contin-
as of April 1, 2015 and is adjusted annually. ued at WGH to expand the Emergency Department and
provide expansion of the Radiology Department along
Insured out-patient hospital services provided to with providing a permanent location for the MRI program
eligible Yukon residents outside Canada are paid at the which started in January 2015.
rate established by the Interprovincial Health Insurance
Agreements Coordinating Committee (IHIACC). For 5.2 Physician Compensation
2015-2016 the in-patient rate was set at $2,383 per day. The Department of Health and Social Services seeks
its negotiating mandate from the Government of Yukon
4.4 Prior Approval Requirement before entering into negotiations with the Yukon Medical
There is no legislated requirement that eligible residents Association (YMA). The YMA and the government each
must seek prior approval before seeking elective or appoint members to the negotiating team. Meetings are
emergency hospital or physician services outside Yukon held as required until an agreement has been reached.
or outside Canada. The YMA’s negotiating team then seeks approval of
the tentative agreement from the YMA membership.
When treatment is provided outside Yukon or outside
The Department seeks ratification of the agreement
Canada plan members will only be reimbursed the
from the Government of Yukon. The final agreement is
amounts as described in Sections 4.2 and 4.3.
signed with the concurrence of both parties. The current
Prior approval by the Director of Insured Health Services Memorandum of Understanding will expire on March
is required for full reimbursement of services sought 31, 2017.
outside of Canada.
The legislation governing payments to physicians and
dentists for insured services are the Health Care
5.0 ACCESSIBILITY Insurance Plan Act and the Health Care Insurance Plan
Regulations. No amendments were made to these
5.1 Access to Insured Health Services sections of the legislation in 2015–2016.
There are no user fees or co-insurance charges under the
Yukon Health Care Insurance Plan or the Yukon Hospital The fee-for-service system is used to reimburse the
Insurance Services Plan. All services are provided on a majority of physicians providing insured services to res-
uniform basis and are not impeded by financial or other idents. Other systems of reimbursement include contract
barriers. There is no extra-billing in Yukon for any services payments and sessional payments, and for services in
covered by the Plan. Whitehorse as well as rural communities in the territory.
Access to hospital or physician services not available 5.3 Payments to Hospitals

locally are provided through the Visiting Specialist Program, The Government of Yukon funds the Yukon Hospital
Telehealth Program or the Travel for Medical Treatment Corporation (Whitehorse General Hospital, Watson Lake
Program. These programs ensure that there is minimal or Community Hospital, and Dawson City Community
no delay in receiving medically necessary services. Hospital) through contribution agreements with the
Department of Health and Social Services. Global
To improve access to insured health services, the operations and maintenance (O&M) and capital funding
number of visiting specialists continues to increase to levels are negotiated and adjusted based on operational
better serve patients in the territory. requirements and utilization projections from prior years.
In addition to the established O&M and capital funding
122
CHAPTER 3 | YUKON
set out in the agreement, provision is made for the hos- 6.0 RECOGNITION GIVEN TO
pital to submit requests for additional funding assis-
tance for implementing new or enhanced programs. FEDERAL TRANSFERS
The legislation governing payments made by the health The Government of Yukon has acknowledged the
care plan to facilities that provide insured hospital federal contributions provided through the Canada
services is the Hospital Insurance Services Plan Act Health Transfer (CHT) in its 2015–2016 annual Main
and Regulations. The legislation and regulations set out Estimates and Public Accounts publications, which are
the legislative framework for payment to hospitals for available publicly. Section 3(1) (d) and (e) of the Health
insured services provided by that hospital to insured Care Insurance Plan Act and section 3 of the Hospital
persons. No amendments were made to these sections Insurance Services Act acknowledge the contribution of
of the legislation in 2015–2016. the Government of Canada.
REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

PUBLIC FACILITIES1
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 2 15 15 15 15 15
Payments for insured health services ($) 3
57,655,576 58,943,422 70,087,418 72,452,732 73,024,981

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
1 Public facilities are the 12 health centres (Beaver Creek, Destruction Bay, Carcross, Carmacks, Faro, Haines Junction, Mayo, Old Crow,
Pelly Crossing, Ross River, Teslin and Whitehorse) and 3 hospitals (Whitehorse, Dawson City and Watson Lake).
2 Watson Lake Nursing Station decommissioned in 2014–2015 with the opening of the new Watson Lake Community Hospital.
3 Includes monies paid to hospitals and community nursing stations.

CHAPTER 3 | YUKON

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total number of claims, in-patient (#) 996 1,173 1,197 1,205 1,242
Total payments, in-patient ($) 4 13,507,016 15,890,700 16,562,129 16,703,371 17,882,023

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
physicians (#).
physicians (#)
physicians (#)
through fee-for-service ($) 5
4 Hospitals have up to a year from date of service to bill jurisdictions. (information is based upon date of service; therefore,
2014–2015 reporting period is still open until March 31, 2016).
5 Includes Visiting Specialists, Member Reimbursements, Locum Doctors, and Optometrist testing paid through fee-for-service.
Excludes services and costs provided by alternative payment agreements.
124
CHAPTER 3 | YUKON

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 3,219,166 3,563,528 3,503,179 3,718,480 3,919,741

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services (#) not available not available not available not available not available
Total payments ($) not available not available not available not available not available

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services provided (#) 14 6
266
6 6 5
Total payments ($) 13,913 21,854 3,827 8,117 1,781
6 Includes direct billings for insured surgical-dental services received outside the territory.

CHAPTER 3 | NORTHWEST TERRITORIES
NO RT H W E ST T ER R ITO R IE S
During the reporting period, the Department of The public authority responsible for the administration
Health and Social Services (DHSS) worked with of the Medical Care Plan is the Director of Medical
Insurance, appointed by the Minister of Health and
the eight Health and Social Services Authorities
Social Services (the Minister), under the Medical Care
(HSSAs) to administer, manage, and deliver in- Act. The Minister establishes Health and Social Service
sured services in the Northwest Territories (NWT). Authorities’ Boards of Management as per section 10 of
the Hospital Insurance and Health and Social Services
Administration Act (HIHSSA) to, among other things,
administer the Hospital Insurance Plan.
During the 2015–2016 fiscal year DHSS carried out
the following legislative activities related to health 1.2 Reporting Relationship
care services: During the reporting period there were eight Health and
Social Service Authorities (HSSAs): Tlicho Community
• An Act to Amend the Hospital Insurance and
Services Agency (TCSA), Stanton Territorial Health
Health and Social Services Administration Act was
Authority, Yellowknife HSSA, Sahtu HSSA, Beaufort-
passed June 4, 2015. The Bill will come into force
Delta HSSA, Deh Cho HSSA, Fort Smith HSSA and
August 1, 2016, allowing for the establishment of a
Hay River HSSA. They report to the Minister and the
territorial health and social services authority, and
Department of Health and Social Services (DHSS), and
amalgamating six of the existing Health and Social
plan, manage, deliver and evaluate a wide spectrum of
Services Authorities. The Bill also requires that the
health and social services at both the community and
Minister of Health and Social Services develop a
facility level throughout the NWT. These Boards of
territorial plan for health and social services. Together
Management manage, control and operate health and
these changes are intended to improve patient care,
social services facilities within the government’s existing
system integration and accountability.
resources, legislation, policies and directives; and are
•
Drafting regulations under the Health and Social accountable to the Minister.
Services Professions Act continued. The Act, expected
The Minister appoints the Director of Medical Insurance
to come into force in 2017, will allow for the regulation
who is responsible for administering the Medical Care
of several health and social services professions under
Act and its Regulations. The Director prepares an annual
one legislative model. This will modernize existing leg-
report for the Minister on the operation of the Medical
islation, resulting in greater efficiency and consistency.
Care Plan. This report can be found within the DHSS
• A new Mental Health Act was passed October 8, Annual Report.
2015. Once in force, the Act will provide for a more
Boards of Management also administer the Hospital
modern legislative framework that is similar to legisla-
Insurance Plan. The Minister appoints a chairperson and
tion across Canada. The primary purpose of the new
members to the Board of Management for each HSSA
Act is to ensure that those suffering from mental
in the NWT. The chairperson’s term is indefinite and
illness receive appropriate mental health care and
members serve for three years. The exception to this is
treatment as soon as possible and in the least restric-
the TCSA where the Tlicho community governments are
tive manner. The Act will also provide modern and
responsible for appointing one member to the Board.
comprehensive rights for patients and those acting on
The Minister Responsible for Aboriginal Affairs and
behalf of patients.
Intergovernmental Relations (DAAIR) appoints a chair-
person. Members serve for a maximum of four years
1.0 PUBLIC ADMINISTRATION and the chairperson’s term is fixed by the Minister of
DAAIR. The Minister may appoint a Public Administrator
1.1 Health Care Insurance Plan and Public Authority to assume the role of a board of management in certain
The Northwest Territories Health Care Plan consists of circumstances if the Minister feels it is necessary. At
the Medical Care Plan and the Hospital Insurance Plan. reporting time, Public Administrators were in place for
126
the Beaufort Delta, Deh Cho, Stanton Territorial Health Insured out-patient hospital services include:
Authority and Hay River. • laboratory tests;
The Director of Medical Insurance and the Boards of •

diagnostic imaging (including interpretations when
Management are responsible to the Minister, as per needed);
section 8(1)(b) of the Canada Health Act.
• physiotherapy, speech and language pathology therapy
1.3 Audit of Accounts and occupational therapy;
As part of the Government of the Northwest Territories
annual audit, the Office of the Auditor General of Canada •
minor medical and surgical procedures and related
audits payments under the Hospital Insurance Plan and supplies; and
the Medical Care Plan.
•
psychiatric and psychological services under an
approved hospital program.
2.0 COMPREHENSIVENESS The Minister may approve additions or deletions to
insured services provided in the NWT.
Insured hospital services in the Northwest Territories As outlined in the Government of the NWT Medical
(NWT) are provided under the Hospital Insurance and Travel Policy, travel assistance is provided to residents
Health and Social Services Administration Act. with a valid NWT Health Care Card who require medi-
cally necessary insured services that are not available
During the reporting period, insured hospital services
in their home community or elsewhere in the NWT. This
were provided to in-patients and out-patients by 27
ensures that residents of the NWT have reasonable
health facilities throughout the NWT. Consistent with
access to insured hospital and physician services.
Section 9 of the Canada Health Act, the NWT offers
comprehensive range of insured services to its residents. 2.2 Insured Physician Services
The NWT Medical Care Act and the NWT Medical Care
Insured in-patient hospital services include:
Regulations provide for insured physician services.
• meals and accommodation at the ward level;
Medically necessary services provided in approved
• required nursing services; facilities by physicians, nurses, nurse practitioners and
midwives are considered insured services under the
•
laboratory, diagnostic and imaging services (along health care plan. These professionals are required by leg-
with necessary interpretations); islation to be licensed to practice in the NWT under the
Medical Profession Act (physicians), Nursing Profession
• drugs, biologicals and other preparations administered Act (nurses and nurse practitioners) and the Midwifery
in the hospital; Profession Act (registered midwives).
• surgical supplies and use of operating room; For the period 2015–2016, there were 324 licensed phy-
• case room and anesthesiology services; sicians (resident, locum and visiting) active in the NWT.
• radiology and rehab therapy (physio, audio, occupational Physicians may opt out and collect fees other than under
and speech); the Medical Care Plan by providing written notice to the
Director of Medical Insurance. There were no opted-out
•
psychiatric and psychological services within an physicians in the NWT during the reporting period.
approved program; and
The Medical Care Plan insures all medically neces-
• detoxification at approved centers. sary physician services such as:
• diagnosis and treatment of illness and injury;

• surgery, including anaesthetic services; For NWT residents to receive items and/or services that
are generally considered uninsured under the health
• obstetrical care, including prenatal and postnatal care; care plan, prior approval is required. A Medical Advisor
and makes recommendations to the Director of Medical
Insurance regarding the appropriateness of the request.
• eye examinations, treatment and operations provided
by an ophthalmologist. The Workers’ Safety and Compensation Committee
has several policies that are applied when interpreting
The Director of Medical Insurance is responsible for
workers’ compensation acts. These policies are available
recommending an insured services tariff for services
on their website at www.wscc.nt.ca.
payable by the NWT Medical Care Plan for the Minister’s
approval. The Minister ultimately determines if services Changes to the list of uninsured hospital, physician and
will be added, altered or removed from the tariff by: surgical-dental services may be made by the Minister.
• establishing a medical care plan that provides insured
services to insured persons by medical practitioners
3.0 UNIVERSALITY
that will qualify and enable the NWT to receive
transfer payments from the Government of Canada 3.1 Eligibility
under the Canada Health Act; and The Medical Care Act and the Hospital Insurance and
Health and Social Services Administration Act (HIHSSA)
•
approving the fees and charges itemized in the
define eligibility for the NWT Health Care Plan. The NWT
tariff that may be paid in respect to insured services
uses guidelines that are consistent with the legislation
rendered by medical practitioners in the NWT and the
and Interprovincial Agreement on Eligibility and Portability
conditions under which fees and charges are payable.
to determine eligibility in order to fulfill obligations of
2.3 Insured Surgical-Dental Services section 10 in the Canada Health Act.
Licensed oral surgeons may submit claims for insured
Individuals ineligible for NWT health care coverage are
surgical-dental work in the NWT. The Province of Alberta’s
members of the Canadian Forces, federal inmates and
Schedule of Oral and Maxillofacial Surgery Benefits is
new residents who have not completed the minimum
used as a guide.
waiting period. For persons moving back to Canada, eligibil-
2.4 Uninsured Hospital, Physician and ity is restored when permanent residency is established.
Surgical-Dental Services
In order to register for the NWT Health Care Plan,
Not all services provided by hospitals, medical practi-
residents fill out an application form and provide appli-
tioners and dentists are covered under the NWT Health
cable supporting documentation (e.g., visa, immigration
Care Plan. Some uninsured services include:
papers, and proof of residency). Residents may register
• in-vitro fertilization; prior to the date they become eligible. Registration is
directly linked to eligibility for coverage and claims are
• third party examinations; only paid if the client has registered.
• dental services that are not surgical in nature; As of March 31, 2016, there were 43,430 individuals
registered with the NWT Health Care Plan.
• medical-legal services;
• advice or prescriptions done over the phone; Holders of employment visas, student visas and, in
some cases, visitor visas are covered if they meet the
• services rendered to the physician’s family; and,
provisions of the Eligibility and Portability Agreement
• services carried out by people who usually are not and guidelines for health care plan coverage.
medical practitioners such as osteopaths, naturopaths
Babies born to NWT residents outside of Canada are
and chiropractors. Physiotherapy, psychiatry and psy-
automatically covered effective on the date of birth if:
chological therapies are not covered if delivered in a
• At least one parent is a Canadian citizen;
non-approved location.
128
• The parent(s) has: 4.0 PORTABILITY

• approved temporary absence coverage under NWT 4.1 Minimum Waiting Period
Health Care; and Waiting periods for persons moving to the NWT are
consistent with the Interprovincial Agreement on
• an intended date of return to the NWT
Eligibility and Portability. The waiting period ends the
Foreign students and workers are eligible for coverage first day of the third month of residency for those moving
if they hold study/work permits valid for a period of 12 permanently to the NWT.
months or longer. Those holding permits of less than 12
4.2 Coverage During Temporary Absences in Canada
months are not eligible for coverage.
Section 4(2) of the Medical Care Act provides NWT
Permanent residents (landed immigrants) and returning residents with access to insured health coverage
permanent residents are covered on the first day of arrival while temporarily out of the NWT but still in Canada,
in the NWT provided the NWT is their first place of resi- consistent with section 11(1) (b)(i) of the Canada Health
dence in Canada, and they intend to reside in the NWT. Act. The Department of Health and Social Services
(DHSS) adheres to the Interprovincial Agreement on
Convention refugees are covered provided they provide Eligibility and Portability as described in the NWT Health
appropriate documentation. Care Plan Registration Manual.
The following are not eligible for an NWT Health Once an individual has filled out the Temporary Absence
Care Card as they are not considered residents: form and it is approved by DHSS, NWT residents are
• Tourists covered for up to one year of temporary absence for
work, travel or holidays. Full-time students attending
• Visitors post-secondary school are covered as well. The full cost
• Transients of insured services is paid for all services received in
other Canadian jurisdictions.
• Remand clients from other jurisdictions
When a valid NWT health care card is produced,
• Canadian students, who are not NWT residents, at- most doctor visits and hospital services are billed
tending an educational institution in the NWT (unless directly to the Department. During the reporting period,
the student intends to establish a permanent residence 25 million dollars were paid out for hospital in-patient and
in the NWT). Permanent residence does not include out-patient services in other provinces and territories.
student housing or living on campus. Reimbursement guidelines exist for patients having to
pay up front for medically required services.
• A person who works in the NWT but does not intend
to maintain a permanent residence (over 12 months) in The NWT participates in both the Hospital Reciprocal
the NWT (s.7, Interprovincial Agreement on Eligibility Billing Agreement and the Medical Reciprocal Billing
and Portability of Hospital and Medical Care Insurance). Agreement with other jurisdictions (except Quebec).
• Temporary Resident Permit holders. (Temporary Resident 4.3 Coverage During Temporary
Permits (TRP) are issued by the Federal Immigration Absences Outside Canada
Minister and are issued to individuals who, for some As per section 4(3) of the Medical Care Act and
reason, do not meet the immigration requirements but section 11(1)(b) (ii) of the Canada Health Act, the NWT
are admitted to Canada for compassionate or humani- provides reimbursement for NWT residents who require
tarian reasons. The duration of the TRP varies but they medically necessary services while temporarily outside
can be issued for up to 3 years.) Canada. Individuals are required to pay up front and seek
reimbursement upon their return to the NWT. Costs
•
Individuals without valid documentation from for eligible services, including inpatient services, out-
Immigration, Refugees and Citizenship Canada 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 5.3 Payments to Hospitals
be the individual’s permanent residence upon return is Contribution agreements between the Department of
required. Health and Social Services and the Boards of Management
for each Health and Social Service Authority (HSSA) dictate
4.4 Prior Approval Requirement payments made to hospitals. Government budgets,
Prior approval is required for elective services rendered resources and levels of services offered determine the
in other provinces and outside Canada. All services from allocated amounts.
private facilities require prior approval as well.
Payments to HSSAs providing insured hospital services
are governed under the Hospital Insurance and Health
5.0 ACCESSIBILITY and Social Services Administration Act and the Financial
Administration Act. A comprehensive budget is used to
5.1 Access to Insured Health Services fund hospitals in the NWT.
The Government of the NWT Medical Travel Policy
provides NWT residents with assistance to access
medically necessary insured services not available in 6.0 RECOGNITION GIVEN TO
their home community or in the NWT, consistent with
section 12(1)(a) of the Canada Health Act. FEDERAL TRANSFERS
Diagnostic Imaging/Picture Archiving Communication Federal funding from the Canada Health Transfer has
System (DI/PACS) is available everywhere that digital been recognized and reported by the Government of
imaging services are offered. DI/PACS has moved x-rays NWT through the Public Accounts of the Government of
from film to digital format. Radiologists in Yellowknife Northwest Territories, for the Fiscal Year, ended March
and the south can review results in as fast as 35 31, 2015 (published February 2016), the Business Plan:
minutes. This ultimately provides NWT residents with Health and Social Services, 2015-2016, and a Government
access to specialists in southern Canada without having of the NWT press release (December 22, 2015).
to spend extended periods of time away from home
The Public Accounts (noted above) contain the
and family.
consolidated financial statements of the Government
Extra-billing is not permitted in the NWT, in adherence of the Northwest Territories, audited by the Auditor
to section 18 of the Canada Health Act and section 14(1) General of Canada is presented annually to the
of the NWT Medical Care Act. The only exception is Legislative Assembly and the Business Plan (noted
if a medical practitioner opts out of the Medical Care above) is presented annually to the Standing Committee
Plan and collects his or her own fees. This did not occur on Social Development.
during the reporting period.
User charges are also not permitted under section 14(2)

of the NWT Medical Care Act in the NWT unless the
medical practitioner has opted out of the Medical Care
Plan, collects his or her own fees and gives reasonable
notice of the intention to collect fees.

The Department, in close consultation with the NWT
Medical Association, sets physician compensation. Gen-
erally, family and specialist practitioners are compensat-
ed through contractual agreements with the Government
of NWT, while the remainder are compensated on a fee-
for-service basis. Fee-for-service rates in the NWT are
itemized in the Insured Services Tariff approved by the
Minister in accordance with the NWT Medical Care Act.
130
REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 27 27 27 27 27
Payments for insured health services ($) 1 57,225,434 62,112,381 62,499,951 69,659,642 69,872,078

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Payments to private for-profit facilities for not applicable not applicable not applicable not applicable not applicable

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
All data are subject to future revisions.

1 Payments for insured health services are estimated and include only those health services occuring within acute care facilities
(i.e. hospitals that offer both in-patient and out-patient services).


Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
physicians (#) 2
physicians (#)
physicians (#)
through all payment methods ($) 3

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 4,591,143 5,337,436 5,187,669 5,575,668 6,381,924

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services (#) 102 115 111 73 158
Total payments ($) 9,841 18,672 11,348 5,208 168,789

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of participating dentists (#) not available not available not available not available not available
Number of services provided (#) not available not available not available not available not available
2 Estimated based on total active physicians for each fiscal year.

3 Payments are based on expenditures for physician services for NWT residents (including physician remuneration and clinic costs).
132
CHAPTER 3 | NUNAVUT
NU NAV UT
The Department of Health faces many unique In 2015–2016 an additional $17,150,000 was allocated to
challenges when providing for the health and the Department for capital projects.5 The Department of
Health 2015–2016 capital projects included: continued
well-being of Nunavummiut. Of a total popula-
work on the replacement of the Arctic Bay Health Centre
tion of 37,0191 approximately 49 per cent of the and preliminary work of the replacement of the Cape
population is under the age of 25 years (17, 961 Dorset Health Centre.6
people)2, however the 55-59 age group had the
largest annual growth at 10.8 per cent from July
2014 to July 2015.3 The territory is made up of
1.0 PUBLIC ADMINISTRATION
25 communities located across three time zones 1.1 Health Care Insurance Plan and Public Authority
and divided into three regions: Qikiqtaaluk, The Health Care Insurance Plans of Nunavut, including
physician and hospital services, are administered by the
Kivalliq and Kitikmeot.
Department of Health on a non-profit basis.
The Medical Care Act (NWT, 1988 and as duplicated for

The Government of Nunavut incorporates Inuit societal Nunavut by section 29 of the Nunavut Act, 1999) governs
values into program and policy development, as well as the entitlement to and payment of benefits for insured
into service design and delivery. The delivery of health ser- medical services. The Hospital Insurance and Health and
vices in Nunavut is based on a primary health care model. Social Services Administration Act (NWT, 1988 and as
Nunavut’s primary health care providers are family physi- duplicated for Nunavut by section 29 of the Nunavut Act,
cians, nurse practitioners, midwives, community health 1999) enables the establishment of hospital and other
nurses, and other allied health professionals. health services.
In 2015–2016, the territorial operations and maintenance The Department is responsible for delivering health care
budget for the Department of Health was $317,489,000 services to Nunavummiut, including the operation of
including supplementary appropriations.4 One third of the community health centres, regional health centres, and
Department’s total operational budget was spent on costs a hospital. There are three regional offices that manage
associated with medical travel and treatment provided in the delivery of health services at a regional level. Iqaluit
out-of-territory facilities. Nunavut is a vast territory with a operations are administered separately. The Government
low population density and limited health infrastructure, for of Nunavut opted for decentralization to regional offices
example, diagnostic services; therefore, access to a range to support front-line workers and community based deliv-
of hospital and specialist services often requires that resi- ery of a wide range of health programs and services.
dents be sent out of the territory for care.
1 Nunavut Bureau of Statistics, Population Estimates July 1, 2015, 3 Nunavut Bureau of Statistics, Population Estimates July 1, 2015,
http://www.stats.gov.nu.ca/Publications/Popest/Population/Population http://www.stats.gov.nu.ca/Publications/Popest/Population/Population
%20Estimates%20Report,%20July%201,%202015.pdf. %20Estimates%20Report,%20July%201,%202015.pdf.
Population estimates are based on the 2011 census counts adjusted Population estimates are based on the 2011 census counts adjusted
for net census under coverage. Nunavut totals include unorganized for net census under coverage. Nunavut totals include unorganized
areas and outpost camps. areas and outpost camps.
2 Nunavut Bureau of Statistics, Population Estimates July 1, 2015, 4 Department of Health, Division of Finance Freebalance Report
http://www.stats.gov.nu.ca/Publications/Popest/Population/Population 5 2015/2016 Capital Estimates, Government of Nunavut
%20Estimates%20Report,%20July%201,%202015.pdf.
6 2015/2016 Capital Estimates, Government of Nunavut
Population estimates are based on the 2011 census counts adjusted
for net census under coverage. Nunavut totals include unorganized
areas and outpost camps.

CHAPTER 3 | NUNAVUT
1.2 Reporting Relationship diagnostic imaging, respiratory therapy, and health records
Legislation governing the administration of health ser- and information.
vices in Nunavut was carried over from the Northwest
Territories (as Nunavut statutes) pursuant to the Nunavut Currently Rankin Inlet is providing 24-hour care for
Act. The Medical Care Act governs who is covered by the in-patients; out-patients receive care by on-call staff.
Nunavut Health Care Plan and the payment of benefits Cambridge Bay is providing daily clinic hours, and
for insured medical services. Section 23(1) of the Medical emergency care is available, on-call, 24-hours a day.
Care Act requires the Minister responsible for the Act to There are also a limited number of birthing beds at
appoint a Director of Medical Insurance. both facilities. Other community health centres provide
public health services, out-patient services and urgent
The Director is responsible for the administration of the treatment services.
Act and Regulations. Section 24 requires the Director
to submit an annual report on the operation of the Public health services are provided at public health clinics
Nunavut Health Care Plan to the Minister for tabling located in Rankin Inlet and Iqaluit. Public health program-
in the Legislative Assembly. On October 22, 2015 the ing is provided in the remaining communities through
Director of Medical Insurance Annual Report 2014 – 2015 the local health centre. The Department also operates a
was tabled in the Legislative Assembly. Family Practice Clinic, led by Nurse Practitioners, in Iqaluit.
1.3 Audit of Accounts The Family Practice Clinic has the ability to consult
The Auditor General of Canada is the auditor of the physicians and specialists as needed. It was established
Government of Nunavut in accordance with section 30.1 in 2006 with funding from the Primary Health Care
of the Financial Administration Act (Nunavut, 1999). The Transition Fund, and has been successful in helping to
Auditor General is required to conduct an annual audit of reduce pressure on the emergency and out-patient
the transactions and consolidated financial statements departments of the QGH during working hours. The clinic
of the Government of Nunavut. The most recent audited provides a steady source of primary care appointments
report was issued October 29, 2015. and initiatives, such as a Diabetes Clinic and a Sexual
Health Program.
The Department is responsible for authorizing, licensing, in-

2.0 COMPREHENSIVENESS specting and supervising all health facilities in the territory.
Insured in-patient hospital services include: accommo-
Insured hospital services are provided in Nunavut under
dation and meals at the standard ward level; necessary
the authority of the Hospital Insurance and Health and
nursing services; laboratory, radiological and other diag-
Social Services Administration Act and Regulations, sec-
nostic procedures, together with the necessary inter-
tions 2 to 4. No amendments were made to the Act or
pretations; drugs, biological and related preparations
Regulations in 2015–2016.
prescribed by a physician and administered in hospital;
In 2015–2016 insured hospital services were delivered routine surgical supplies; use of operating room, case-
in 28 facilities across Nunavut including: one general room and anaesthetic facilities; use of radiotherapy
hospital (Iqaluit); two regional health facilities (Rankin and physiotherapy services where available; psychiatric
Inlet and Cambridge Bay); 22 community health centres; services provided under an approved program; services
two public health facilities (Iqaluit and Rankin Inlet); and rendered by persons who are paid by the hospital.
one family practice clinic (Iqaluit). Rehabilitative treatment
Out-patient services include: laboratory tests and x-rays,
is available through the Timimut Ikajuksivik Centre located
including interpretations, when requested by a physician
in Iqaluit or via contracted services in other regions.
and performed in an out-patient facility or in an approved
The Qikiqtani General Hospital (QGH) is currently the hospital; hospital services in connection with most mi-
only acute care facility in Nunavut providing a range of nor medical and surgical procedures; physiotherapy, oc-
in-and out-patient hospital services as defined by the cupational therapy, limited audiology and speech therapy
Canada Health Act. QGH offers 24-hour emergency ser- services in an out-patient facility or in an approved hospi-
vices, in-patient care (including obstetrics, paediatrics tal; and psychiatric services provided under an approved
and palliative care), surgical services, laboratory services, hospital program.
134
CHAPTER 3 | NUNAVUT
The Department makes the determination to add insured in Nunavut, the patient is referred to another jurisdic-
hospital services based on the availability of appropriate tion to obtain the insured service. Nunavut has health
resources, equipment and overall feasibility in accordance service agreements with medical and treatment
with financial guidelines set by the Department and with centres in Ottawa, Winnipeg, Churchill, Yellowknife and
the approval of the Financial Management Board. No new Edmonton. These are the out-of-territory sites to which
services were added in 2015–2016 to the list of insured Nunavut mainly refers its patients to access medical
hospital services. services not available within the territory.
2.2 Insured Physician Services The addition or deletion of insured physician services
The Medical Care Act, section 3(1), and Medical Care requires government approval. For this, the Director of
Regulations, section 3, provide for insured physician Medical Insurance would become involved in negotia-
services in Nunavut. No amendments were made to tions with a collective group of physicians to discuss
the Act or Regulation in 2015–2016. The Nursing Act the service. Then the decision of the group would be
allows for licensure of nurse practitioners in Nunavut; this presented to Cabinet for approval. No insured physician
permits nurses to deliver insured services in Nunavut. services were added or deleted in 2015–2016.
Upon initial registration physicians must be in good 2.3 Insured Surgical-Dental Services
standing with a College of Physicians and Surgeons Dentists providing insured surgical-dental services
from a Canadian jurisdiction, and be licensed to practice under the Nunavut Health Care Plan must be licensed
in Nunavut. The Government of Nunavut’s Medical pursuant to the Dental Professions Act (NWT, 1988 and
Registration Committee currently manages this process as duplicated for Nunavut by section 29 of the Nunavut
for Nunavut physicians. Nunavut recruits and contracts Act, 1999). Billing numbers are provided for billing the
its own family physicians, and accesses specialist services Plan regarding the provision of insured dental services.
primarily from its main referral centres in Ottawa,
Edmonton, Winnipeg, and Yellowknife. Recruitment of Insured dental services are limited to those dental-
full-time family physicians has improved significantly surgical procedures scheduled in the Regulations, re-
and there are 26 family physician positions, covered quiring the unique capabilities of a hospital for their
by a combination of locums and full-time physicians, performance; for example, orthognathic surgery. Oral
funded through the Department, providing over 7,501 surgeons are brought to Nunavut on a regular basis, but
days of service annually across the territory. on rare occasions, for medically complicated situations,
patients are flown out of the territory.
Of the 26 full-time family physician positions in Nunavut,
16 are in the Qikiqtaaluk region; 7.5 in the Kivalliq region; The addition of new surgical-dental services to the list of
and 2.5 in the Kitikmeot region. There are also 1.5 general insured services requires government approval. No new
surgeons, one anaesthetist, and one paediatrician at the services were added to the list in 2015–2016.
QGH. Visiting specialists, general practitioners and locums
also provide insured physician services; these arrange-
Surgical-Dental Services
ments are made by each of the Department’s three regions.
Services provided under the Workers’ Compensation Act
Physicians can elect to collect fees other than those under (NWT, 1988 and as duplicated for Nunavut by section 29
the Medical Care Plan in accordance with section 12(2) of the Nunavut Act, 1999) or other Acts of Canada, except
(a) or (b) of the Medical Care Act by notifying the Director the Canada Health Act, are excluded.
in writing. An election can be revoked the first day of the
Services provided by physicians that are not insured
following month after a letter to that effect is delivered
include: yearly physicals; cosmetic surgery; services
to the Director. In 2015–2016, no physicians provided
that are considered experimental; prescription drugs;
written notice of this election. All physicians practicing
physical examinations done at the request of a third party;
in Nunavut are under contract with the Department. In
optometric services; dental services other than specific
2015–2016, 278 physicians provided service in Nunavut.
procedures related to jaw injury or disease; the services
Insured physician services refer to all services rendered of chiropractors, naturopaths, podiatrists, osteopaths
by medical practitioners that are medically required. and acupuncture treatments; and physiotherapy, speech
Where insured services are unavailable in some places therapy and psychology services received in a facility that
is not an insured out-patient facility (hospital).

CHAPTER 3 | NUNAVUT
Services not covered in a hospital include: hospital Registration requirements include a completed applica-
charges above the standard ward rate for private or tion form and supporting documentation. A health care
semi-private accommodation; services that are not card is issued to each resident. To streamline document
medically required, such as cosmetic surgery; services processing, a staggered renewal process is used. No
that are considered experimental; ambulance charges premiums exist. Coverage under the Nunavut Medical
(except inter-hospital transfers); dental services, other Insurance Plan is linked to verification of registration,
than specific procedures related to jaw injury or disease; although every effort is made to ensure registration
and alcohol and drug rehabilitation, without prior approval. occurs when a coverage issue arises for an eligible
resident. For non-residents, a valid health care card from
In 2015–2016 the Qikiqtani General Hospital charged their home province or territory is required.
a $2,380 per diem rate for services provided for non-
Canadian resident stays. The inpatient rate charged in Coverage generally begins the first day of the third
Rankin Inlet and Cambridge Bay was $1,337. month after arrival in Nunavut, but first-day coverage is
provided under a number of circumstances, for example,
When residents are sent out of the territory for services, newborns whose mothers or fathers are eligible for cov-
the Department relies on the policies and procedures erage. Permanent residents (landed immigrants), returning
guiding that particular jurisdiction when they provide Canadians, repatriated Canadians, returning permanent
services to Nunavut residents that could result in residents, and non-Canadians who have been issued an
additional costs, only to the extent that these costs employment visa for a period of 12 months or more, are
are covered by Nunavut’s Medical Insurance Plan (see also granted first-day coverage.
section 4.2 below). Any query or complaint is handled
on an individual basis with the jurisdiction involved. Members of the Canadian Armed Forces and inmates
of a federal penitentiary are not eligible for registration.
The Department also administers the Non-Insured Health These groups are granted first-day coverage under the
Benefits (NIHB) Program, on behalf of Health Canada, for Nunavut Health Care Plan upon discharge.
Inuit and First Nations residents in Nunavut. NIHB covers
a co-payment for medical travel, accommodations and Pursuant to section 7 of the Interprovincial Agreement
meals at boarding homes (in Ottawa, Winnipeg, Churchill, on Eligibility and Portability, individuals in Nunavut who
Edmonton, Yellowknife and Iqaluit), prescription drugs, are temporarily absent from their home province or
dental treatment, vision care, medical supplies and pros- territory and who are not establishing residency in Nunavut
theses, and a number of other incidental services. remain covered by their home provincial or territorial
health insurance plans for up to one year.
3.0 UNIVERSALITY On March 31, 2016, 37,764 individuals were registered

with the Nunavut Health Care Plan, up by 1,097 from the
3.1 Eligibility previous year. There are no formal provisions for Nunavut
Eligibility for the Nunavut Health Care Plan is briefly de- residents to opt out of the Nunavut Health Care Plan.
fined under sections 3(1), (2), and (3) of the Medical Care
Act. The Department also adheres to the Interprovincial 3.2 Other Categories of Individuals
Agreement on Eligibility and Portability, as well as internal Non-Canadian holders of employment visas of less than
guidelines. No amendments were made to the Act or 12 months, foreign students with visas of less than 12
Regulations in 2015–2016. months, transient workers, and individuals holding a
Minister’s Permit (with the possible exception of those
Subject to these provisions, every Nunavut resident is holding a temporary resident permit who may be
eligible for and entitled to insured health services on reviewed on a case by case basis) are not eligible for
uniform terms and conditions. A resident means a coverage. When unique circumstances occur, assess-
person lawfully entitled to be in or to remain in Canada, ments are done on an individual basis. This is consistent
who makes his or her home and is ordinarily present with section 15 of the Northwest Territories’ Guidelines
in Nunavut, but does not include a tourist, transient or for Health Care Plan Registration, which was adopted by
visitor to Nunavut. Eligible residents receive a health card Nunavut in 1999.
with a unique health care number.
136
CHAPTER 3 | NUNAVUT
4.0 PORTABILITY Nunavut residents receiving insured services outside the

territory. Payment is made to the host province at the
4.1 Minimum Waiting Period rates established by that province.
Consistent with section 3 of the Interprovincial Agreement
on Eligibility and Portability, the waiting period before 4.3 Coverage During Temporary Absences
coverage begins for individuals moving within Canada is Outside Canada
three months, or the first day of the third month following The Medical Care Act, section 4(3), prescribes the
the establishment of residency in a new province or benefits payable where insured medical services are
territory, or the first day of the third month when an provided outside Canada. The Hospital Insurance and
individual, who has been temporarily absent from his Health and Social Services Administration Act, section
or her home province, decides to take up permanent 28(1)(j)(o), provides the authority for the Minister to
residency in Nunavut. set the terms and conditions of payment for services
provided to Nunavut residents outside Canada.
4.2 Coverage During Temporary Absences in Canada Individuals are granted coverage for up to one year if
The Medical Care Act, section 4(2), prescribes the ben- they are temporarily out of the country for any reason,
efits payable where insured medical services are provided although they must give prior notice in writing. For
outside Nunavut, but within Canada. The Hospital services provided to residents who have been referred
Insurance and Health and Social Services Administration out of the country for highly specialized procedures
Act, sections 5(d) and 28(1)(j)(o), provide the authority unavailable in Nunavut and Canada, Nunavut will pay the
for the Minister to enter into agreements with other full cost. For non-referred or emergency services, the
jurisdictions to provide health services to Nunavut resi- payment for hospital services is $2,380 per day and for
dents, and the terms and conditions of payment. No out-patient care it is $309 per day.
legislative or regulatory changes were made in 2015–
2016 with respect to coverage outside Nunavut. Insured physician services provided to eligible residents
temporarily outside the country are paid at rates equiv-
Students studying outside Nunavut must notify the alent to those paid had that service been provided in
Department and provide proof of enrollment to ensure the territory. Reimbursement is made to the insured
continuing coverage. Requests for extensions must individual or directly to the provider of the insured service.
be renewed yearly and are subject to approval by the
Director. Temporary absences for work, vacation or 4.4 Prior Approval Requirement
other reasons for up to one year are approved by the Prior approval is required to receive reimbursement for
Director upon receipt of a written request from the elective services provided in private facilities in Canada
insured person. The Director may approve absences or in any facility outside the country.
in excess of 12 continuous months upon receiving a
written request from the insured individual.
5.0 ACCESSIBILITY
The provisions regarding coverage during temporary
absences in Canada fully comply with the terms and 5.1 Access to Insured Health Services
conditions of the Interprovincial Agreement on Eligibility The Medical Care Act, section 14, prohibits extra-
and Portability. Nunavut participates in physician and billing by physicians unless the medical practitioner has
hospital reciprocal billing. As well, special bilateral made an election that is still in effect. Access to insured
agreements are in place with Ontario, Manitoba, Alberta, services is provided on uniform terms and conditions.
and the Northwest Territories. The Hospital Reciprocal To break down the barrier posed by distance and cost
Billing Agreements provide payment of in- and out-patient of travel, the Government of Nunavut provides medical
hospital services to eligible Nunavut residents receiving travel assistance. Interpretation services in Inuktut are
insured services outside the territory. High-cost also provided to patients.
procedure rates, newborn rates, and out-patient rates are The Qikiqtani General Hospital (QGH) in Iqaluit is
based on those established by the Interprovincial Health currently the only acute care hospital facility in Nunavut.
Insurance Agreements Coordinating Committee. The The hospital has a total of 35 beds available for acute,
Physician Reciprocal Billing Agreements provide payment rehabilitative, palliative and chronic care services but
of insured physician services on behalf of eligible currently only 20 general purpose beds are in use due to

CHAPTER 3 | NUNAVUT
capacity and need. There are also four birthing rooms and 5.2 Physician Compensation
six day surgery beds. The facility provides in-patient, All full-time physicians in Nunavut work under contract
out-patient and 24-hour emergency services. On-site with the Department. The terms of the contracts are set
physicians provide emergency services on rotation. by the Department. Visiting consultants are paid a daily
Medical services provided include: an ambulatory care/ contract rate for their professional services. Rates vary
out-patient clinic, limited intensive care services, and based on services rendered.
general medical, maternity and palliative care. Surgical
services provided include ophthalmology, urology, ortho- 5.3 Payments to Hospitals
paedics, gynaecology, paediatrics, general surgery, Funding for the Qikiqtani General Hospital, regional
emergency trauma, otolaryngology and dental surgery health facilities and community health centres is provided
under general anesthesia and conscious sedation. through the Government of Nunavut’s budget process.
Patients requiring specialized surgeries are sent to other
jurisdictions. Diagnostic services include: radiology,
laboratory, electrocardiogram and CT scans. 6.0 RECOGNITION GIVEN TO
FEDERAL TRANSFERS
Outside of Iqaluit, out-patient and 24-hour emergency
nursing services are provided by local health centres in Nunavummiut are aware of ongoing federal contri-
Nunavut’s 24 other communities. butions through press releases and media coverage.
The Government of Nunavut has also recognized the
Nunavut has two Continuing Care Centres located in federal contribution provided through the Canada Health
Igloolik and Gjoa Haven. These facilities provide full time Transfer in various published documents. For fiscal year
nursing and personal care to adults. Each facility has 10 2015–2016, they included:
beds.
• 2015–2016 Fiscal and Economic Indicators; and
Nunavut has agreements in place with a number of
out-of-territory regional health authorities and specific • 2015–2018 Government of Nunavut Business Plan.
facilities to provide medical specialists and other
visiting health practitioner services. The following spe-
cialist services were provided in Nunavut during 2015–
2016 under the visiting specialists program: ophthalmol-
ogy, orthopaedics, internal medicine, otolaryngology,
neurology, rheumatology, dermatology, paediatrics,
obstetrics/gynecology, urology, respirology, cardiology,
physiotherapy, occupational therapy, psychiatry, oral
surgery, and allergist. Visiting specialist clinics are held
depending on demand and availability of specialists.
Nunavut’s Telehealth network, linking all 25 commu-

nities, allows for the delivery of a broad range of ser-
vices 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.
138
CHAPTER 3 | NUNAVUT
REGISTERED PERSONS
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number as of March 31st (#) 1
35,893 35,041 35,897 36,667 37,764

PUBLIC FACILITIES
Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number (#) 28 28 28 28 28

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments, in-patient ($) 0 4,410 20,574 0 2,780
Total payments, out-patients ($) 0 0 20,041 25,388 12,411
The difference in the number of registered Nunavut residents and those covered under the Nunavut Health Care Plan is due to delays
1
in the reconciliation of data on residents who have left the territory.

CHAPTER 3 | NUNAVUT

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
physicians (#)
physicians (#)
physicians (#)
Total payments for services 334,359 403,418 348,473 54,501 152,815
through fee-for-service ($) 2,3

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Total payments ($) 4
6,393,341 6,341,047 6,855,743 7,607,809 8,088,273

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of services (#) 22 15 82 29 14
Total payments ($) 963 732 7,346 1,803 667

Year 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
Number of participating dentists (#) not available not available not available not available not available
Number of services provided (#) not available not available not available not available not available
2 Typically, Nunavut does not pay its physicians through fee-for-service. Instead, the majority of physicians are compensated through
contracted salaries.
3 For 2015-2016 this is the amount as of December 2016.
4 For 2015-2016 this is the amount as of August 2016. Bills are accepted until March 2017.
140
ANNEX A | CANADA HEALTH ACT AND EXTRA-BILLING AND USER CHARGES INFORMATION REGULATIONS
A NN EX A
CANADA HEALTH ACT AND

EXTRA-BILLING AND USER CHARGES
INFORMATION REGULATIONS
This annex provides the reader with an office consolidation
of the Canada Health Act and the Extra-billing and User
Charges Information Regulations. An office consolidation
is a rendering of the original Act, which includes any
amendments that have been made since the Act’s pas-
sage. 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 reconcili-
ations with any estimated charges can be made. These
regulations are also presented in an office consolidation
format. This unofficial consolidation is current to December
8, 2016. It is provided for the convenience of the reader
only. For the official text of the Canada Health Act, please
contact Justice Canada.

CANADA
CONSOLIDATION CODIFICATION
Canada Health Act Loi canadienne sur la santé
R.S.C., 1985, c. C-6 L.R.C. (1985), ch. C-6
Current to December 8, 2016 À jour au 8 décembre 2016
Last amended on June 29, 2012 Dernière modification le 29 juin 2012
Published by the Minister of Justice at the following address: Publié par le ministre de la Justice à l’adresse suivante :
http://laws-lois.justice.gc.ca http://lois-laws.justice.gc.ca
142
OFFICIAL STATUS CARACTÈRE OFFICIEL

OF CONSOLIDATIONS DES CODIFICATIONS
Subsections 31(1) and (2) of the Legislation Revision and Les paragraphes 31(1) et (2) de la Loi sur la révision et la
Consolidation Act, in force on June 1, 2009, provide as codification des textes législatifs, en vigueur le 1er juin
follows: 2009, prévoient ce qui suit :
Published consolidation is evidence Codifications comme élément de preuve

31 (1) Every copy of a consolidated statute or consolidated 31 (1) Tout exemplaire d'une loi codifiée ou d'un règlement
regulation published by the Minister under this Act in either codifié, publié par le ministre en vertu de la présente loi sur
print or electronic form is evidence of that statute or regula- support papier ou sur support électronique, fait foi de cette
tion and of its contents and every copy purporting to be pub- loi ou de ce règlement et de son contenu. Tout exemplaire
lished by the Minister is deemed to be so published, unless donné comme publié par le ministre est réputé avoir été ainsi
the contrary is shown. publié, sauf preuve contraire.
Inconsistencies in Acts Incompatibilité — lois

(2) In the event of an inconsistency between a consolidated (2) Les dispositions de la loi d'origine avec ses modifications
statute published by the Minister under this Act and the origi- subséquentes par le greffier des Parlements en vertu de la Loi
nal statute or a subsequent amendment as certified by the sur la publication des lois l'emportent sur les dispositions in-
Clerk of the Parliaments under the Publication of Statutes compatibles de la loi codifiée publiée par le ministre en vertu
Act, the original statute or amendment prevails to the extent de la présente loi.
of the inconsistency.
NOTE NOTE
This consolidation is current to December 8, 2016. The Cette codification est à jour au 8 décembre 2016. Les
last amendments came into force on June 29, 2012. Any dernières modifications sont entrées en vigueur
amendments that were not in force as of December 8, le 29 juin 2012. Toutes modifications qui n'étaient pas en
2016 are set out at the end of this document under the vigueur au 8 décembre 2016 sont énoncées à la fin de ce
heading “Amendments Not in Force”. document sous le titre « Modifications non en vigueur ».


R.S.C., 1985, c. C-6 L.R.C., 1985, ch. C-6
An Act relating to cash contributions by Loi concernant les contributions pécuniaires

Canada and relating to criteria and du Canada ainsi que les principes et
conditions in respect of insured health conditions applicables aux services de santé
services and extended health care services assurés et aux services complémentaires de
santé
Preamble Préambule
WHEREAS the Parliament of Canada recognizes: Considérant que le Parlement du Canada reconnaît :
—that it is not the intention of the Government of que le gouvernement du Canada n’entend pas par la
Canada that any of the powers, rights, privileges or présente loi abroger les pouvoirs, droits, privilèges
authorities vested in Canada or the provinces under ou autorités dévolus au Canada ou aux provinces
the provisions of the Constitution Act, 1867, or any sous le régime de la Loi constitutionnelle de 1867 et
amendments thereto, or otherwise, be by reason of de ses modifications ou à tout autre titre, ni leur dé-
this Act abrogated or derogated from or in any way roger ou porter atteinte,
impaired;
que les Canadiens ont fait des progrès remarquables,
—that Canadians, through their system of insured grâce à leur système de services de santé assurés,
health services, have made outstanding progress in dans le traitement des maladies et le soulagement
treating sickness and alleviating the consequences of des affections et déficiences parmi toutes les catégo-
disease and disability among all income groups; ries socio-économiques,
—that Canadians can achieve further improvements que les Canadiens peuvent encore améliorer leur
in their well-being through combining individual bien-être en joignant à un mode de vie individuel axé
lifestyles that emphasize fitness, prevention of dis- sur la condition physique, la prévention des maladies
ease and health promotion with collective action et la promotion de la santé, une action collective
against the social, environmental and occupational contre les causes sociales, environnementales ou in-
causes of disease, and that they desire a system of dustrielles des maladies et qu’ils désirent un système
health services that will promote physical and mental de services de santé qui favorise la santé physique et
health and protection against disease; mentale et la protection contre les maladies,
—that future improvements in health will require the que les améliorations futures dans le domaine de la
cooperative partnership of governments, health pro- santé nécessiteront la coopération des gouverne-
fessionals, voluntary organizations and individual ments, des professionnels de la santé, des orga-
Canadians; nismes bénévoles et des citoyens canadiens,
—that continued access to quality health care without que l’accès continu à des soins de santé de qualité,
financial or other barriers will be critical to maintain- sans obstacle financier ou autre, sera déterminant
ing and improving the health and well-being of Cana- pour la conservation et l’amélioration de la santé et
dians; du bien-être des Canadiens;
AND WHEREAS the Parliament of Canada wishes to considérant en outre que le Parlement du Canada
encourage the development of health services souhaite favoriser le développement des services de
Current to December 8, 2016 1 À jour au 8 décembre 2016

144
Canada Health Santé

Short Title Titre abrégé
Sections 1-2 Articles 1-2
throughout Canada by assisting the provinces in santé dans tout le pays en aidant les provinces à en
meeting the costs thereof; supporter le coût,
NOW, THEREFORE, Her Majesty, by and with the ad- Sa Majesté, sur l’avis et avec le consentement du Sé-
vice and consent of the Senate and House of Com- nat et de la Chambre des communes du Canada,
mons of Canada, enacts as follows: édicte :

Short title Titre abrégé
1 This Act may be cited as the Canada Health Act. 1 Loi canadienne sur la santé.
1984, c. 6, s. 1. 1984, ch. 6, art. 1.
Interpretation Définitions
Definitions Définitions
2 In this Act, 2 Les définitions qui suivent s’appliquent à la présente
loi.
Act of 1977 [Repealed, 1995, c. 17, s. 34]
assuré Habitant d’une province, à l’exception :
cash contribution means the cash contribution in re-
spect of the Canada Health Transfer that may be provid- a) des membres des Forces canadiennes;
ed to a province under sections 24.2 and 24.21 of the Fed-
eral-Provincial Fiscal Arrangements Act; (contribution b) [Abrogé, 2012, ch. 19, art. 377]
pécuniaire)
c) des personnes purgeant une peine d’emprisonne-
contribution [Repealed, 1995, c. 17, s. 34] ment dans un pénitencier, au sens de la Partie I de la
Loi sur le système correctionnel et la mise en liberté
dentist means a person lawfully entitled to practise den- sous condition;
tistry in the place in which the practice is carried on by
that person; (dentiste) d) des habitants de la province qui s’y trouvent depuis
une période de temps inférieure au délai minimal de
extended health care services means the following ser- résidence ou de carence d’au plus trois mois imposé
vices, as more particularly defined in the regulations, aux habitants par la province pour qu’ils soient admis-
provided for residents of a province, namely, sibles ou aient droit aux services de santé assurés. (in-
sured person)
(a) nursing home intermediate care service,
contribution [Abrogée, 1995, ch. 17, art. 34]
(b) adult residential care service,
contribution pécuniaire La contribution au titre du
(c) home care service, and Transfert canadien en matière de santé qui peut être ver-
sée à une province au titre des articles 24.2 et 24.21 de la
(d) ambulatory health care service; (services complé- Loi sur les arrangements fiscaux entre le gouvernement
mentaires de santé) fédéral et les provinces. (cash contribution)
extra-billing means the billing for an insured health ser- dentiste Personne légalement autorisée à exercer la mé-
vice rendered to an insured person by a medical practi- decine dentaire au lieu où elle se livre à cet exercice.
tioner or a dentist in an amount in addition to any (dentist)
amount paid or to be paid for that service by the health
care insurance plan of a province; (surfacturation) frais modérateurs Frais d’un service de santé assuré au-
torisés ou permis par un régime provincial d’assurance-
health care insurance plan means, in relation to a santé mais non payables, soit directement soit indirecte-
province, a plan or plans established by the law of the ment, au titre d’un régime provincial d’assurance-santé,
province to provide for insured health services; (régime
d’assurance-santé)



Section 2 Article 2
health care practitioner means a person lawfully enti- à l’exception des frais imposés par surfacturation. (user
tled under the law of a province to provide health ser- charge)
vices in the place in which the services are provided by
that person; (professionnel de la santé) habitant Personne domiciliée et résidant habituellement
dans une province et légalement autorisée à être ou à res-
hospital includes any facility or portion thereof that pro- ter au Canada, à l’exception d’une personne faisant du
vides hospital care, including acute, rehabilitative or tourisme, de passage ou en visite dans la province. (resi-
chronic care, but does not include dent)
(a) a hospital or institution primarily for the mentally hôpital Sont compris parmi les hôpitaux tout ou partie
disordered, or des établissements où sont fournis des soins hospitaliers,
notamment aux personnes souffrant de maladie aiguë ou
(b) a facility or portion thereof that provides nursing chronique ainsi qu’en matière de réadaptation, à l’excep-
home intermediate care service or adult residential tion :
care service, or comparable services for children; (hô-
pital) a) des hôpitaux ou institutions destinés principale-
ment aux personnes souffrant de troubles mentaux;
hospital services means any of the following services
provided to in-patients or out-patients at a hospital, if b) de tout ou partie des établissements où sont four-
the services are medically necessary for the purpose of nis des soins intermédiaires en maison de repos ou
maintaining health, preventing disease or diagnosing or des soins en établissement pour adultes ou des soins
treating an injury, illness or disability, namely, comparables pour les enfants. (hospital)
(a) accommodation and meals at the standard or pub- loi de 1977 [Abrogée, 1995, ch. 17, art. 34]
lic ward level and preferred accommodation if medi-
cally required, médecin Personne légalement autorisée à exercer la mé-
decine au lieu où elle se livre à cet exercice. (medical
(b) nursing service, practitioner)
(c) laboratory, radiological and other diagnostic pro- ministre Le ministre de la Santé. (Minister)
cedures, together with the necessary interpretations,
professionnel de la santé Personne légalement autori-
(d) drugs, biologicals and related preparations when sée en vertu de la loi d’une province à fournir des services
administered in the hospital, de santé au lieu où elle les fournit. (health care practi-
tioner)
(e) use of operating room, case room and anaesthetic
facilities, including necessary equipment and supplies, régime d’assurance-santé Le régime ou les régimes
constitués par la loi d’une province en vue de la presta-
(f) medical and surgical equipment and supplies,
tion de services de santé assurés. (health care insurance
(g) use of radiotherapy facilities, plan)
(h) use of physiotherapy facilities, and services complémentaires de santé Les services défi-
nis dans les règlements et offerts aux habitants d’une
(i) services provided by persons who receive remuner- province, à savoir :
ation therefor from the hospital,
a) les soins intermédiaires en maison de repos;
but does not include services that are excluded by the
regulations; (services hospitaliers) b) les soins en établissement pour adultes;
insured health services means hospital services, physi- c) les soins à domicile;
cian services and surgical-dental services provided to in-
d) les soins ambulatoires. (extended health care ser-
sured persons, but does not include any health services
that a person is entitled to and eligible for under any oth- vices)
er Act of Parliament or under any Act of the legislature of
services de chirurgie dentaire Actes de chirurgie den-
a province that relates to workers' or workmen’s compen-
taire nécessaires sur le plan médical ou dentaire, accom-
sation; (services de santé assurés)
plis par un dentiste dans un hôpital, et qui ne peuvent

146

Section 2 Article 2
insured person means, in relation to a province, a resi- être accomplis convenablement qu’en un tel établisse-
dent of the province other than ment. (surgical-dental services)
(a) a member of the Canadian Forces, services de santé assurés Services hospitaliers, médi-
caux ou de chirurgie dentaire fournis aux assurés, à l’ex-
(b) [Repealed, 2012, c. 19, s. 377] ception des services de santé auxquels une personne a
droit ou est admissible en vertu d’une autre loi fédérale
(c) a person serving a term of imprisonment in a peni- ou d’une loi provinciale relative aux accidents du travail.
tentiary as defined in the Penitentiary Act, or (insured health services)
(d) a resident of the province who has not completed services hospitaliers Services fournis dans un hôpital
such minimum period of residence or waiting period, aux malades hospitalisés ou externes, si ces services sont
not exceeding three months, as may be required by the médicalement nécessaires pour le maintien de la santé, la
province for eligibility for or entitlement to insured prévention des maladies ou le diagnostic ou le traitement
health services; (assuré) des blessures, maladies ou invalidités, à savoir :
medical practitioner means a person lawfully entitled to a) l’hébergement et la fourniture des repas en salle
practise medicine in the place in which the practice is commune ou, si médicalement nécessaire, en chambre
carried on by that person; (médecin) privée ou semi-privée;
Minister means the Minister of Health; (ministre) b) les services infirmiers;
physician services means any medically required ser- c) les actes de laboratoires, de radiologie ou autres
vices rendered by medical practitioners; (services médi- actes de diagnostic, ainsi que les interprétations né-
caux) cessaires;
resident means, in relation to a province, a person law- d) les produits pharmaceutiques, substances biolo-
fully entitled to be or to remain in Canada who makes his giques et préparations connexes administrés à l’hôpi-
home and is ordinarily present in the province, but does tal;
not include a tourist, a transient or a visitor to the
province; (habitant) e) l’usage des salles d’opération, des salles d’accou-
chement et des installations d’anesthésie, ainsi que le
surgical-dental services means any medically or dental- matériel et les fournitures nécessaires;
ly required surgical-dental procedures performed by a
dentist in a hospital, where a hospital is required for the f) le matériel et les fournitures médicaux et chirurgi-
proper performance of the procedures; (services de chi- caux;
rurgie dentaire)
g) l’usage des installations de radiothérapie;
user charge means any charge for an insured health ser-
h) l’usage des installations de physiothérapie;
vice that is authorized or permitted by a provincial health
care insurance plan that is not payable, directly or indi-
i) les services fournis par les personnes rémunérées à
rectly, by a provincial health care insurance plan, but
cet effet par l’hôpital.
does not include any charge imposed by extra-billing.
(frais modérateurs) Ne sont pas compris parmi les services hospitaliers les
R.S., 1985, c. C-6, s. 2; 1992, c. 20, s. 216(F); 1995, c. 17, s. 34; 1996, c. 8, s. 32; 1999, c.
26, s. 11; 2012, c. 19, ss. 377, 407.
services exclus par les règlements. (hospital services)
services médicaux Services médicalement nécessaires

fournis par un médecin. (physician services)
surfacturation Facturation de la prestation à un assuré

par un médecin ou un dentiste d’un service de santé as-
suré, en excédent par rapport au montant payé ou à
payer pour la prestation de ce service au titre du régime
provincial d’assurance-santé. (extra-billing)
L.R. (1985), ch. C-6, art. 2; 1992, ch. 20, art. 216(F); 1995, ch. 17, art. 34; 1996, ch. 8, art.
32; 1999, ch. 26, art. 11; 2012, ch. 19, art. 377 et 407.


Canadian Health Care Policy Politique canadienne de la santé
Canadian Health Care Policy Politique canadienne de la santé

Primary objective of Canadian health care policy Objectif premier
3 It is hereby declared that the primary objective of 3 La politique canadienne de la santé a pour premier ob-
Canadian health care policy is to protect, promote and jectif de protéger, de favoriser et d’améliorer le bien-être
restore the physical and mental well-being of residents of physique et mental des habitants du Canada et de facili-
Canada and to facilitate reasonable access to health ser- ter un accès satisfaisant aux services de santé, sans obs-
vices without financial or other barriers. tacles d’ordre financier ou autre.
1984, c. 6, s. 3. 1984, ch. 6, art. 3.
Purpose Raison d’être

Purpose of this Act Raison d’être de la présente loi
4 The purpose of this Act is to establish criteria and con- 4 La présente loi a pour raison d’être d’établir les condi-
ditions in respect of insured health services and extended tions d’octroi et de versement d’une pleine contribution
health care services provided under provincial law that pécuniaire pour les services de santé assurés et les ser-
must be met before a full cash contribution may be made. vices complémentaires de santé fournis en vertu de la loi
R.S., 1985, c. C-6, s. 4; 1995, c. 17, s. 35. d’une province.
L.R. (1985), ch. C-6, art. 4; 1995, ch. 17, art. 35.
Cash Contribution Contribution pécuniaire

Cash contribution Contribution pécuniaire
5 Subject to this Act, as part of the Canada Health 5 Sous réserve des autres dispositions de la présente loi,
Transfer, a full cash contribution is payable by Canada to le Canada verse à chaque province, pour chaque exercice,
each province for each fiscal year. une pleine contribution pécuniaire à titre d’élément du
R.S., 1985, c. C-6, s. 5; 1995, c. 17, s. 36; 2012, c. 19, s. 408. Transfert canadien en matière de santé (ci-après,
« Transfert »).
L.R. (1985), ch. C-6, art. 5; 1995, ch. 17, art. 36; 2012, ch. 19, art. 408.
6 [Repealed, 1995, c. 17, s. 36] 6 [Abrogé, 1995, ch. 17, art. 36]
Program Criteria Conditions d’octroi

Program criteria Règle générale
7 In order that a province may qualify for a full cash 7 Le versement à une province, pour un exercice, de la
contribution referred to in section 5 for a fiscal year, the pleine contribution pécuniaire visée à l’article 5 est assu-
health care insurance plan of the province must, jetti à l’obligation pour le régime d’assurance-santé de
throughout the fiscal year, satisfy the criteria described satisfaire, pendant tout cet exercice, aux conditions d’oc-
in sections 8 to 12 respecting the following matters: troi énumérées aux articles 8 à 12 quant à :
(a) public administration; a) la gestion publique;
(b) comprehensiveness; b) l’intégralité;
(c) universality; c) l’universalité;
(d) portability; and d) la transférabilité;
(e) accessibility. e) l’accessibilité.

1984, c. 6, s. 7. 1984, ch. 6, art. 7.

148

Public administration Gestion publique

8 (1) In order to satisfy the criterion respecting public 8 (1) La condition de gestion publique suppose que :
administration,
a) le régime provincial d’assurance-santé soit géré
(a) the health care insurance plan of a province must sans but lucratif par une autorité publique nommée ou
be administered and operated on a non-profit basis by désignée par le gouvernement de la province;
a public authority appointed or designated by the gov-
ernment of the province; b) l’autorité publique soit responsable devant le gou-
vernement provincial de cette gestion;
(b) the public authority must be responsible to the
provincial government for that administration and op- c) l’autorité publique soit assujettie à la vérification
eration; and de ses comptes et de ses opérations financières par
l’autorité chargée par la loi de la vérification des
(c) the public authority must be subject to audit of its comptes de la province.
accounts and financial transactions by such authority
as is charged by law with the audit of the accounts of
the province.
Designation of agency permitted Désignation d’un mandataire

(2) The criterion respecting public administration is not (2) La condition de gestion publique n’est pas enfreinte
contravened by reason only that the public authority re- du seul fait que l’autorité publique visée au paragraphe
ferred to in subsection (1) has the power to designate any (1) a le pouvoir de désigner un mandataire chargé :
agency
a) soit de recevoir en son nom les montants payables
(a) to receive on its behalf any amounts payable under au titre du régime provincial d’assurance-santé;
the provincial health care insurance plan; or
b) soit d’exercer en son nom les attributions liées à la
(b) to carry out on its behalf any responsibility in con- réception ou au règlement des comptes remis pour
nection with the receipt or payment of accounts ren- prestation de services de santé assurés si la désigna-
dered for insured health services, if it is a condition of tion est assujettie à la vérification et à l’approbation
the designation that all those accounts are subject to par l’autorité publique des comptes ainsi remis et à la
assessment and approval by the public authority and détermination par celle-ci des montants à payer à cet
that the public authority shall determine the amounts égard.
to be paid in respect thereof. 1984, ch. 6, art. 8.
1984, c. 6, s. 8.
Comprehensiveness Intégralité
9 In order to satisfy the criterion respecting comprehen- 9 La condition d’intégralité suppose qu’au titre du ré-
siveness, the health care insurance plan of a province gime provincial d’assurance-santé, tous les services de
must insure all insured health services provided by hos- santé assurés fournis par les hôpitaux, les médecins ou
pitals, medical practitioners or dentists, and where the les dentistes soient assurés, et lorsque la loi de la pro-
law of the province so permits, similar or additional ser- vince le permet, les services semblables ou additionnels
vices rendered by other health care practitioners. fournis par les autres professionnels de la santé.
1984, c. 6, s. 9. 1984, ch. 6, art. 9.
Universality Universalité
10 In order to satisfy the criterion respecting universali- 10 La condition d’universalité suppose qu’au titre du ré-
ty, the health care insurance plan of a province must en- gime provincial d’assurance-santé, cent pour cent des as-
title one hundred per cent of the insured persons of the surés de la province ait droit aux services de santé assu-
province to the insured health services provided for by rés prévus par celui-ci, selon des modalités uniformes.
the plan on uniform terms and conditions. 1984, ch. 6, art. 10.
1984, c. 6, s. 10.


Section 11 Article 11
Portability Transférabilité
11 (1) In order to satisfy the criterion respecting porta- 11 (1) La condition de transférabilité suppose que le ré-
bility, the health care insurance plan of a province gime provincial d’assurance-santé :
(a) must not impose any minimum period of resi- a) n’impose pas de délai minimal de résidence ou de
dence in the province, or waiting period, in excess of carence supérieur à trois mois aux habitants de la pro-
three months before residents of the province are eli- vince pour qu’ils soient admissibles ou aient droit aux
gible for or entitled to insured health services; services de santé assurés;
(b) must provide for and be administered and operat- b) prévoie et que ses modalités d’application assurent
ed so as to provide for the payment of amounts for the le paiement des montants pour le coût des services de
cost of insured health services provided to insured santé assurés fournis à des assurés temporairement
persons while temporarily absent from the province absents de la province :
on the basis that
(i) si ces services sont fournis au Canada, selon le
(i) where the insured health services are provided taux approuvé par le régime d’assurance-santé de la
in Canada, payment for health services is at the rate province où ils sont fournis, sauf accord de réparti-
that is approved by the health care insurance plan tion différente du coût entre les provinces concer-
of the province in which the services are provided, nées,
unless the provinces concerned agree to apportion
the cost between them in a different manner, or (ii) s’il sont fournis à l’étranger, selon le montant
qu’aurait versé la province pour des services sem-
(ii) where the insured health services are provided blables fournis dans la province, compte tenu, s’il
out of Canada, payment is made on the basis of the s’agit de services hospitaliers, de l’importance de
amount that would have been paid by the province l’hôpital, de la qualité des services et des autres fac-
for similar services rendered in the province, with teurs utiles;
due regard, in the case of hospital services, to the
size of the hospital, standards of service and other c) prévoie et que ses modalités d’application assurent
relevant factors; and la prise en charge, pendant le délai minimal de rési-
dence ou de carence imposé par le régime d’assu-
(c) must provide for and be administered and operat- rance-santé d’une autre province, du coût des services
ed so as to provide for the payment, during any mini- de santé assurés fournis aux personnes qui ne sont
mum period of residence, or any waiting period, im- plus assurées du fait qu’elles habitent cette province,
posed by the health care insurance plan of another dans les mêmes conditions que si elles habitaient en-
province, of the cost of insured health services provid- core leur province d’origine.
ed to persons who have ceased to be insured persons
by reason of having become residents of that other
province, on the same basis as though they had not
ceased to be residents of the province.
Requirement for consent for elective insured health Consentement préalable à la prestation des services
services permitted de santé assurés facultatifs
(2) The criterion respecting portability is not contra- (2) La condition de transférabilité n’est pas enfreinte du
vened by a requirement of a provincial health care insur- fait qu’il faut, aux termes du régime d’assurance-santé
ance plan that the prior consent of the public authority d’une province, le consentement préalable de l’autorité
that administers and operates the plan must be obtained publique qui le gère pour la prestation de services de san-
for elective insured health services provided to a resident té assurés facultatifs à un habitant temporairement ab-
of the province while temporarily absent from the sent de la province, si ces services y sont offerts selon des
province if the services in question were available on a modalités sensiblement comparables.
substantially similar basis in the province.
Definition of "elective insured health services" Définition de « services de santé assurés facultatifs »
(3) For the purpose of subsection (2), elective insured (3) Pour l’application du paragraphe (2), services de
health services means insured health services other santé assurés facultatifs s’entend des services de santé
than services that are provided in an emergency or in any assurés, à l’exception de ceux qui sont fournis d’urgence

150

other circumstance in which medical care is required ou dans d’autres circonstances où des soins médicaux
without delay. sont requis sans délai.
1984, c. 6, s. 11. 1984, ch. 6, art. 11.
Accessibility Accessibilité
12 (1) In order to satisfy the criterion respecting acces- 12 (1) La condition d’accessibilité suppose que le ré-
sibility, the health care insurance plan of a province gime provincial d’assurance-santé :
(a) must provide for insured health services on uni- a) offre les services de santé assurés selon des modali-
form terms and conditions and on a basis that does tés uniformes et ne fasse pas obstacle, directement ou
not impede or preclude, either directly or indirectly indirectement, et notamment par facturation aux as-
whether by charges made to insured persons or other- surés, à un accès satisfaisant par eux à ces services;
wise, reasonable access to those services by insured
persons; b) prévoie la prise en charge des services de santé as-
surés selon un tarif ou autre mode de paiement autori-
(b) must provide for payment for insured health ser- sé par la loi de la province;
vices in accordance with a tariff or system of payment
authorized by the law of the province; c) prévoie une rémunération raisonnable de tous les
services de santé assurés fournis par les médecins ou
(c) must provide for reasonable compensation for all les dentistes;
insured health services rendered by medical practi-
tioners or dentists; and d) prévoie le versement de montants aux hôpitaux, y
compris les hôpitaux que possède ou gère le Canada, à
(d) must provide for the payment of amounts to hos- l’égard du coût des services de santé assurés.
pitals, including hospitals owned or operated by Cana-
da, in respect of the cost of insured health services.
Reasonable compensation Rémunération raisonnable

(2) In respect of any province in which extra-billing is (2) Pour toute province où la surfacturation n’est pas
not permitted, paragraph (1)(c) shall be deemed to be permise, il est réputé être satisfait à l’alinéa (1)c) si la
complied with if the province has chosen to enter into, province a choisi de conclure un accord et a effective-
and has entered into, an agreement with the medical ment conclu un accord avec ses médecins et dentistes
practitioners and dentists of the province that provides prévoyant :
(a) for negotiations relating to compensation for in- a) la tenue de négociations sur la rémunération des
sured health services between the province and services de santé assurés entre la province et les orga-
provincial organizations that represent practising nisations provinciales représentant les médecins ou
medical practitioners or dentists in the province; dentistes qui exercent dans la province;
(b) for the settlement of disputes relating to compen- b) le règlement des différends concernant la rémuné-
sation through, at the option of the appropriate ration par, au choix des organisations provinciales
provincial organizations referred to in paragraph (a), compétentes visées à l’alinéa a), soit la conciliation
conciliation or binding arbitration by a panel that is soit l’arbitrage obligatoire par un groupe représentant
equally representative of the provincial organizations également les organisations provinciales et la province
and the province and that has an independent chair- et ayant un président indépendant;
man; and
c) l’impossibilité de modifier la décision du groupe vi-
(c) that a decision of a panel referred to in paragraph sé à l’alinéa b), sauf par une loi de la province.
(b) may not be altered except by an Act of the legisla- 1984, ch. 6, art. 12.
ture of the province.
1984, c. 6, s. 12.


Conditions for Cash Contribution Contribution pécuniaire assujettie à des conditions
Conditions for Cash Contribution pécuniaire

Contribution assujettie à des conditions
Conditions Obligations de la province
13 In order that a province may qualify for a full cash 13 Le versement à une province de la pleine contribu-
contribution referred to in section 5, the government of tion pécuniaire visée à l’article 5 est assujetti à l’obliga-
the province tion pour le gouvernement de la province :
(a) shall, at the times and in the manner prescribed by a) de communiquer au ministre, selon les modalités
the regulations, provide the Minister with such infor- de temps et autres prévues par les règlements, les ren-
mation, of a type prescribed by the regulations, as the seignements du genre prévu aux règlements, dont ce-
Minister may reasonably require for the purposes of lui-ci peut normalement avoir besoin pour l’applica-
this Act; and tion de la présente loi;
(b) shall give recognition to the Canada Health Trans- b) de faire état du Transfert dans tout document pu-
fer in any public documents, or in any advertising or blic ou toute publicité sur les services de santé assurés
promotional material, relating to insured health ser- et les services complémentaires de santé dans la pro-
vices and extended health care services in the vince.
province. L.R. (1985), ch. C-6, art. 13; 1995, ch. 17, art. 37; 2012, ch. 19, art. 409(A).
R.S., 1985, c. C-6, s. 13; 1995, c. 17, s. 37; 2012, c. 19, s. 409(E).
Defaults Manquements
Referral to Governor in Council Renvoi au gouverneur en conseil
14 (1) Subject to subsection (3), where the Minister, af- 14 (1) Sous réserve du paragraphe (3), dans le cas où il
ter consultation in accordance with subsection (2) with estime, après avoir consulté conformément au para-
the minister responsible for health care in a province, is graphe (2) son homologue chargé de la santé dans une
of the opinion that province :
(a) the health care insurance plan of the province does a) soit que le régime d’assurance-santé de la province
not or has ceased to satisfy any one of the criteria de- ne satisfait pas ou plus aux conditions visées aux ar-
scribed in sections 8 to 12, or ticles 8 à 12;
(b) the province has failed to comply with any condi- b) soit que la province ne s’est pas conformée aux
tion set out in section 13, conditions visées à l’article 13,
and the province has not given an undertaking satisfacto- et que celle-ci ne s’est pas engagée de façon satisfaisante
ry to the Minister to remedy the default within a period à remédier à la situation dans un délai suffisant, le mi-
that the Minister considers reasonable, the Minister shall nistre renvoie l’affaire au gouverneur en conseil.
refer the matter to the Governor in Council.
Consultation process Étapes de la consultation

(2) Before referring a matter to the Governor in Council (2) Avant de renvoyer une affaire au gouverneur en
under subsection (1) in respect of a province, the Minis- conseil conformément au paragraphe (1) relativement à
ter shall une province, le ministre :
(a) send by registered mail to the minister responsible a) envoie par courrier recommandé à son homologue
for health care in the province a notice of concern with chargé de la santé dans la province un avis sur tout
respect to any problem foreseen; problème éventuel;
(b) seek any additional information available from the b) tente d’obtenir de la province, par discussions bila-
province with respect to the problem through bilateral térales, tout renseignement additionnel disponible sur
discussions, and make a report to the province within le problème et fait rapport à la province dans les
ninety days after sending the notice of concern; and quatre-vingt-dix jours suivant l’envoi de l’avis;

152

(c) if requested by the province, meet within a reason- c) si la province le lui demande, tient une réunion
able period of time to discuss the report. dans un délai acceptable afin de discuter du rapport.
Where no consultation can be achieved Impossibilité de consultation

(3) The Minister may act without consultation under (3) Le ministre peut procéder au renvoi prévu au para-
subsection (1) if the Minister is of the opinion that a suf- graphe (1) sans consultation préalable s’il conclut à l’im-
ficient time has expired after reasonable efforts to possibilité d’obtenir cette consultation malgré des efforts
achieve consultation and that consultation will not be sérieux déployés à cette fin au cours d’un délai conve-
achieved. nable.
1984, c. 6, s. 14. 1984, ch. 6, art. 14.
Order reducing or withholding contribution Décret de réduction ou de retenue

15 (1) Where, on the referral of a matter under section 15 (1) Si l’affaire lui est renvoyée en vertu de l’article 14
14, the Governor in Council is of the opinion that the et qu’il estime que le régime d’assurance-santé de la pro-
health care insurance plan of a province does not or has vince ne satisfait pas ou plus aux conditions visées aux
ceased to satisfy any one of the criteria described in sec- articles 8 à 12 ou que la province ne s’est pas conformée
tions 8 to 12 or that a province has failed to comply with aux conditions visées à l’article 13, le gouverneur en
any condition set out in section 13, the Governor in conseil peut, par décret :
Council may, by order,
a) soit ordonner, pour chaque manquement, que la
(a) direct that any cash contribution to that province contribution pécuniaire d’un exercice à la province
for a fiscal year be reduced, in respect of each default, soit réduite du montant qu’il estime indiqué, compte
by an amount that the Governor in Council considers tenu de la gravité du manquement;
to be appropriate, having regard to the gravity of the
default; or b) soit, s’il l’estime indiqué, ordonner la retenue de la
totalité de la contribution pécuniaire d’un exercice à la
(b) where the Governor in Council considers it appro- province.
priate, direct that the whole of any cash contribution
to that province for a fiscal year be withheld.
Amending orders Modification des décrets

(2) The Governor in Council may, by order, repeal or (2) Le gouverneur en conseil peut, par décret, annuler ou
amend any order made under subsection (1) where the modifier un décret pris en vertu du paragraphe (1) s’il
Governor in Council is of the opinion that the repeal or l’estime justifié dans les circonstances.
amendment is warranted in the circumstances.
Notice of order Avis

(3) A copy of each order made under this section togeth- (3) Le texte de chaque décret pris en vertu du présent ar-
er with a statement of any findings on which the order ticle de même qu’un exposé des motifs sur lesquels il est
was based shall be sent forthwith by registered mail to fondé sont envoyés sans délai par courrier recommandé
the government of the province concerned and the Minis- au gouvernement de la province concernée; le ministre
ter shall cause the order and statement to be laid before fait déposer le texte du décret et celui de l’exposé devant
each House of Parliament on any of the first fifteen days chaque chambre du Parlement dans les quinze premiers
on which that House is sitting after the order is made. jours de séance de celle-ci suivant la prise du décret.
Commencement of order Entrée en vigueur du décret

(4) An order made under subsection (1) shall not come (4) Un décret pris en vertu du paragraphe (1) ne peut en-
into force earlier than thirty days after a copy of the order trer en vigueur que trente jours après l’envoi au gouver-
has been sent to the government of the province con- nement de la province concernée du texte du décret aux
cerned under subsection (3). termes du paragraphe (3).
R.S., 1985, c. C-6, s. 15; 1995, c. 17, s. 38. L.R. (1985), ch. C-6, art. 15; 1995, ch. 17, art. 38.



Reimposition of reductions or withholdings Nouvelle application des réductions ou retenues

16 In the case of a continuing failure to satisfy any of the 16 En cas de manquement continu aux conditions visées
criteria described in sections 8 to 12 or to comply with aux articles 8 à 12 ou à l’article 13, les réductions ou rete-
any condition set out in section 13, any reduction or with- nues de la contribution pécuniaire à une province déjà
holding under section 15 of a cash contribution to a appliquées pour un exercice en vertu de l’article 15 lui
province for a fiscal year shall be reimposed for each suc- sont appliquées de nouveau pour chaque exercice ulté-
ceeding fiscal year as long as the Minister is satisfied, af- rieur où le ministre estime, après consultation de son ho-
ter consultation with the minister responsible for health mologue chargé de la santé dans la province, que le man-
care in the province, that the default is continuing. quement se continue.
When reduction or withholding imposed Application aux exercices ultérieurs

17 Any reduction or withholding under section 15 or 16 17 Toute réduction ou retenue d’une contribution pécu-
of a cash contribution may be imposed in the fiscal year niaire visée aux articles 15 ou 16 peut être appliquée pour
in which the default that gave rise to the reduction or l’exercice où le manquement à son origine a eu lieu ou
withholding occurred or in the following fiscal year. pour l’exercice suivant.
Extra-billing and User Charges Surfacturation et frais

modérateurs
Extra-billing Surfacturation
18 In order that a province may qualify for a full cash 18 Une province n’a droit, pour un exercice, à la pleine
contribution referred to in section 5 for a fiscal year, no contribution pécuniaire visée à l’article 5 que si, aux
payments may be permitted by the province for that fis- termes de son régime d’assurance-santé, elle ne permet
cal year under the health care insurance plan of the pas pour cet exercice le versement de montants à l’égard
province in respect of insured health services that have des services de santé assurés qui ont fait l’objet de surfac-
been subject to extra-billing by medical practitioners or turation par les médecins ou les dentistes.
dentists. 1984, ch. 6, art. 18.
1984, c. 6, s. 18.
User charges Frais modérateurs

19 (1) In order that a province may qualify for a full 19 (1) Une province n’a droit, pour un exercice, à la
cash contribution referred to in section 5 for a fiscal year, pleine contribution pécuniaire visée à l’article 5 que si,
user charges must not be permitted by the province for aux termes de son régime d’assurance-santé, elle ne per-
that fiscal year under the health care insurance plan of met pour cet exercice l’imposition d’aucuns frais modéra-
the province. teurs.
Limitation Réserve
(2) Subsection (1) does not apply in respect of user (2) Le paragraphe (1) ne s’applique pas aux frais modé-
charges for accommodation or meals provided to an in- rateurs imposés pour l’hébergement ou les repas fournis
patient who, in the opinion of the attending physician, à une personne hospitalisée qui, de l’avis du médecin
requires chronic care and is more or less permanently traitant, souffre d’une maladie chronique et séjourne de
resident in a hospital or other institution. façon plus ou moins permanente à l’hôpital ou dans une
1984, c. 6, s. 19. autre institution.
1984, ch. 6, art. 19.
Deduction for extra-billing Déduction en cas de surfacturation

20 (1) Where a province fails to comply with the condi- 20 (1) Dans le cas où une province ne se conforme pas à
tion set out in section 18, there shall be deducted from la condition visée à l’article 18, il est déduit de la contri-
the cash contribution to the province for a fiscal year an bution pécuniaire à cette dernière pour un exercice un
amount that the Minister, on the basis of information montant, déterminé par le ministre d’après les

154

Extra-billing and User Charges Surfacturation et frais modérateurs
provided in accordance with the regulations, determines renseignements fournis conformément aux règlements,
to have been charged through extra-billing by medical égal au total de la surfacturation effectuée par les méde-
practitioners or dentists in the province in that fiscal year cins ou les dentistes dans la province pendant l’exercice
or, where information is not provided in accordance with ou, si les renseignements n’ont pas été fournis conformé-
the regulations, an amount that the Minister estimates to ment aux règlements, un montant estimé par le ministre
have been so charged. égal à ce total.
Deduction for user charges Déduction en cas de frais modérateurs

(2) Where a province fails to comply with the condition (2) Dans le cas où une province ne se conforme pas à la
set out in section 19, there shall be deducted from the condition visée à l’article 19, il est déduit de la contribu-
cash contribution to the province for a fiscal year an tion pécuniaire à cette dernière pour un exercice un mon-
amount that the Minister, on the basis of information tant, déterminé par le ministre d’après les renseigne-
provided in accordance with the regulations, determines ments fournis conformément aux règlements, égal au
to have been charged in the province in respect of user total des frais modérateurs assujettis à l’article 19 impo-
charges to which section 19 applies in that fiscal year or, sés dans la province pendant l’exercice ou, si les rensei-
where information is not provided in accordance with the gnements n’ont pas été fournis conformément aux règle-
regulations, an amount that the Minister estimates to ments, un montant estimé par le ministre égal à ce total.
have been so charged.
Consultation with province Consultation de la province

(3) The Minister shall not estimate an amount under (3) Avant d’estimer un montant visé au paragraphe (1)
subsection (1) or (2) without first undertaking to consult ou (2), le ministre se charge de consulter son homologue
the minister responsible for health care in the province responsable de la santé dans la province concernée.
concerned.
Separate accounting in Public Accounts Comptabilisation

(4) Any amount deducted under subsection (1) or (2) (4) Les montants déduits d’une contribution pécuniaire
from a cash contribution in any of the three consecutive en vertu des paragraphes (1) ou (2) pendant les trois
fiscal years the first of which commences on April 1, 1984 exercices consécutifs dont le premier commence le 1er
shall be accounted for separately in respect of each avril 1984 sont comptabilisés séparément pour chaque
province in the Public Accounts for each of those fiscal province dans les comptes publics pour chacun de ces
years in and after which the amount is deducted. exercices pendant et après lequel le montant a été déduit.
Refund to province Remboursement à la province

(5) Where, in any of the three fiscal years referred to in (5) Si, de l’avis du ministre, la surfacturation ou les frais
subsection (4), extra-billing or user charges have, in the modérateurs ont été supprimés dans une province pen-
opinion of the Minister, been eliminated in a province, dant l’un des trois exercices visés au paragraphe (4), il est
the total amount deducted in respect of extra-billing or versé à cette dernière le montant total déduit à l’égard de
user charges, as the case may be, shall be paid to the la surfacturation ou des frais modérateurs, selon le cas.
province.
Saving Réserve
(6) Nothing in this section restricts the power of the (6) Le présent article n’a pas pour effet de limiter le pou-
Governor in Council to make any order under section 15. voir du gouverneur en conseil de prendre le décret prévu
1984, c. 6, s. 20. à l’article 15.
1984, ch. 6, art. 20.
When deduction made Application aux exercices ultérieurs

21 Any deduction from a cash contribution under sec- 21 Toute déduction d’une contribution pécuniaire visée
tion 20 may be made in the fiscal year in which the mat- à l’article 20 peut être appliquée pour l’exercice où le fait
ter that gave rise to the deduction occurred or in the fol- à son origine a eu lieu ou pour les deux exercices sui-
lowing two fiscal years. vants.
1984, c. 6, s. 21. 1984, ch. 6, art. 21.



Regulations Règlements
22 (1) Subject to this section, the Governor in Council 22 (1) Sous réserve des autres dispositions du présent
may make regulations for the administration of this Act article, le gouverneur en conseil peut, par règlement,
and for carrying its purposes and provisions into effect, prendre toute mesure d’application de la présente loi et,
including, without restricting the generality of the fore- notamment :
going, regulations
a) définir les services visés aux alinéas a) à d) de la dé-
(a) defining the services referred to in paragraphs (a) finition de « services complémentaires de santé » à
to (d) of the definition "extended health care services" l’article 2;
in section 2;
b) déterminer les services exclus des services hospita-
(b) prescribing the services excluded from hospital liers;
services;
c) déterminer les genres de renseignements dont peut
(c) prescribing the types of information that the Min- avoir besoin le ministre en vertu de l’alinéa 13a) et
ister may require under paragraph 13(a) and the times fixer les modalités de temps et autres de leur commu-
at which and the manner in which that information nication;
shall be provided; and
d) prévoir la façon dont il doit être fait état du Trans-
(d) prescribing the manner in which recognition to fert en vertu de l’alinéa 13b).
the Canada Health Transfer is required to be given un-
der paragraph 13(b).
Agreement of provinces Consentement des provinces

(2) Subject to subsection (3), no regulation may be made (2) Sous réserve du paragraphe (3), il ne peut être pris de
under paragraph (1)(a) or (b) except with the agreement règlements en vertu des alinéas (1)a) ou b) qu’avec l’ac-
of each of the provinces. cord de chaque province.
Exception Exception
(3) Subsection (2) does not apply in respect of regula- (3) Le paragraphe (2) ne s’applique pas aux règlements
tions made under paragraph (1)(a) if they are substan- pris en vertu de l’alinéa (1)a) s’ils sont sensiblement com-
tially the same as regulations made under the Federal- parables aux règlements pris en vertu de la Loi sur les ar-
Provincial Fiscal Arrangements Act, as it read rangements fiscaux entre le gouvernement fédéral et les
immediately before April 1, 1984. provinces, dans sa version précédant immédiatement le
1er avril 1984.
Consultation with provinces Consultation des provinces

(4) No regulation may be made under paragraph (1)(c) (4) Il ne peut être pris de règlements en vertu des alinéas
or (d) unless the Minister has first consulted with the (1)c) ou d) que si le ministre a au préalable consulté ses
ministers responsible for health care in the provinces. homologues chargés de la santé dans les provinces.
R.S., 1985, c. C-6, s. 22; 1995, c. 17, s. 40; 2012, c. 19, s. 410(E). L.R. (1985), ch. C-6, art. 22; 1995, ch. 17, art. 40; 2012, ch. 19, art. 410(A).
Report to Parliament Rapport au Parlement

Annual report by Minister Rapport annuel du ministre
23 The Minister shall, as soon as possible after the ter- 23 Au plus tard pour le 31 décembre de chaque année, le
mination of each fiscal year and in any event not later ministre établit dans les meilleurs délais un rapport sur
than December 31 of the next fiscal year, make a report l’application de la présente loi au cours du précédent
respecting the administration and operation of this Act exercice, en y incluant notamment tous les renseigne-
for that fiscal year, including all relevant information on ments pertinents sur la mesure dans laquelle les régimes
the extent to which provincial health care insurance provinciaux d’assurance-santé et les provinces ont

156

Report to Parliament Rapport au Parlement
Section 23 Article 23
plans have satisfied the criteria, and the extent to which satisfait aux conditions d’octroi et de versement prévues
the provinces have satisfied the conditions, for payment à la présente loi; le ministre fait déposer le rapport de-
under this Act and shall cause the report to be laid before vant chaque chambre du Parlement dans les quinze pre-
each House of Parliament on any of the first fifteen days miers jours de séance de celle-ci suivant son achèvement.
on which that House is sitting after the report is complet- 1984, ch. 6, art. 23.
ed.
1984, c. 6, s. 23.

CANADA
CONSOLIDATION CODIFICATION
Extra-billing and User Charges Règlement concernant les

Information Regulations renseignements sur la
surfacturation et les frais
modérateurs
SOR/86-259 DORS/86-259
Published by the Minister of Justice at the following address: Publié par le ministre de la Justice à l’adresse suivante :
http://laws-lois.justice.gc.ca http://lois-laws.justice.gc.ca
158
OFFICIAL STATUS CARACTÈRE OFFICIEL

OF CONSOLIDATIONS DES CODIFICATIONS
Subsections 31(1) and (3) of the Legislation Revision and Les paragraphes 31(1) et (3) de la Loi sur la révision et la
Consolidation Act, in force on June 1, 2009, provide as codification des textes législatifs, en vigueur le 1er juin
follows: 2009, prévoient ce qui suit :
Published consolidation is evidence Codifications comme élément de preuve

31 (1) Every copy of a consolidated statute or consolidated 31 (1) Tout exemplaire d'une loi codifiée ou d'un règlement
regulation published by the Minister under this Act in either codifié, publié par le ministre en vertu de la présente loi sur
print or electronic form is evidence of that statute or regula- support papier ou sur support électronique, fait foi de cette
tion and of its contents and every copy purporting to be pub- loi ou de ce règlement et de son contenu. Tout exemplaire
lished by the Minister is deemed to be so published, unless donné comme publié par le ministre est réputé avoir été ainsi
the contrary is shown. publié, sauf preuve contraire.
... [...]
Inconsistencies in regulations Incompatibilité — règlements

(3) In the event of an inconsistency between a consolidated (3) Les dispositions du règlement d'origine avec ses modifica-
regulation published by the Minister under this Act and the tions subséquentes enregistrées par le greffier du Conseil pri-
original regulation or a subsequent amendment as registered vé en vertu de la Loi sur les textes réglementaires l'emportent
by the Clerk of the Privy Council under the Statutory Instru- sur les dispositions incompatibles du règlement codifié publié
ments Act, the original regulation or amendment prevails to par le ministre en vertu de la présente loi.
the extent of the inconsistency.
NOTE NOTE
This consolidation is current to December 8, 2016. Any Cette codification est à jour au 8 décembre 2016. Toutes
amendments that were not in force as of December 8, modifications qui n'étaient pas en vigueur au 8 décembre
2016 are set out at the end of this document under the 2016 sont énoncées à la fin de ce document sous le titre
heading “Amendments Not in Force”. « Modifications non en vigueur ».

Registration Enregistrement
SOR/86-259 February 27, 1986 DORS/86-259 Le 27 février 1986
CANADA HEALTH ACT LOI CANADIENNE SUR LA SANTÉ
Extra-billing and User Charges Information Règlement concernant les renseignements sur la
Regulations surfacturation et les frais modérateurs
P.C. 1986-499 February 27, 1986 C.P. 1986-499 Le 27 février 1986
Whereas the Minister of National Health and Welfare Vu que le ministre de la Santé nationale et du Bien-
has consulted with the Ministers responsible for être social a consulté ses homologues chargés de la
health care in the provinces respecting proposed santé dans les provinces quant au projet de Règle-
Regulations prescribing the types of information that ment déterminant les genres de renseignements sur
the Minister may require under paragraph 13(a) of la surfacturation et les frais modérateurs dont peut
the Canada Health Act in respect of extra-billing and avoir besoin le ministre de la Santé nationale et du
user charges and the times at which and the manner Bien-être social en vertu de l’alinéa 13a) de la Loi ca‐
in which such information shall be provided by the nadienne sur la santé quant à la surfacturation et aux
government of each province. frais modérateurs et fixant les modalités de temps et
les autres modalités de leur communication par le
gouvernement de chaque province;
Therefore, Her Excellency the Governor General in À ces causes, sur avis conforme du ministre de la
Council, on the recommendation of the Minister of Santé nationale et du Bien-être social et en vertu de
National Health and Welfare, pursuant to para- l’alinéa 22(1)c) de la Loi canadienne sur la santé*, il
graph 22(1)(c) of the Canada Health Act*, is pleased plaît à Son Excellence le Gouverneur général en
hereby to make the annexed Regulations prescribing conseil de prendre, à compter du 1er avril 1986, le Rè-
the types of information that the Minister of National glement déterminant les genres de renseignements
Health and Welfare may require under para- dont peut avoir besoin le ministre de la Santé natio-
graph 13(a) of the Canada Health Act in respect of ex‐ nale et du Bien-être social en vertu de l’alinéa 13a) de
tra-billing and user charges and the times at which la Loi canadienne sur la santé quant à la surfactura-
and the manner in which such information shall be tion et aux frais modérateurs et fixant les modalités
provided by the government of each province, effec- de temps et les autres modalités de leur communica-
tive April 1, 1986. tion par le gouvernement de chaque province, ci-
après.
* *
S.C. 1984, c. 6 S.C. 1984, ch. 6
160
Regulations Prescribing the Types of Infor- Règlement déterminant les genres de ren-
mation that the Minister of National Health seignements dont peut avoir besoin le mi‐
and Welfare may Require under Para- nistre de la Santé nationale et du Bien-être
graph 13(a) of the Canada Health Act in Re‐ social en vertu de l’alinéa 13a) de la Loi ca‐
spect of Extra-Billing and User Charges and nadienne sur la santé quant à la surfactura‐
the Times at which and the Manner in which tion et aux frais modérateurs et fixant les
such Information shall be Provided by the modalités de temps et les autres modalités
Government of each Province de leur communication par le gouvernement
de chaque province

1 These Regulations may be cited as the Extra-billing 1 Règlement concernant les renseignements sur la sur-
and User Charges Information Regulations. facturation et les frais modérateurs.
2 In these Regulations, 2 Les définitions qui suivent s’appliquent au présent rè-
glement.
Act means the Canada Health Act; (Loi)
exercice La période commençant le 1er avril d’une année
Minister means the Minister of National Health and et se terminant le 31 mars de l’année suivante. (fiscal
Welfare; (ministre) year)
fiscal year means the period beginning on April 1 in one Loi La Loi canadienne sur la santé. (Act)
year and ending on March 31 in the following year. (exer-
cice) ministre Le ministre de la Santé nationale et du Bien-
être social. (Minister)
Types of Information Genre de renseignements

3 For the purposes of paragraph 13(a) of the Act, the 3 Pour l’application de l’alinéa 13a) de la Loi, le ministre
Minister may require the government of a province to peut exiger que le gouvernement d’une province lui four-
provide the Minister with information of the following nisse les renseignements suivants sur les montants de la
types with respect to extra-billing in the province in a fis- surfacturation pratiquée dans la province au cours d’un
cal year: exercice :
(a) an estimate of the aggregate amount that, at the a) une estimation du montant total de la surfactura-
time the estimate is made, is expected to be charged tion, à la date de l’estimation, accompagnée d’une ex-
through extra-billing, including an explanation re- plication de la façon dont cette estimation a été obte-
garding the method of determination of the estimate; nue;
and
b) un état financier indiquant le montant total de la
(b) a financial statement showing the aggregate surfacturation effectivement imposée, accompagné
amount actually charged through extra-billing, includ- d’une explication de la façon dont cet état a été établi.
ing an explanation regarding the method of determi-
nation of the aggregate amount.
4 For the purposes of paragraph 13(a) of the Act, the 4 Pour l’application de l’alinéa 13a) de la Loi, le ministre
Minister may require the government of a province to peut exiger que le gouvernement d’une province lui

Extra-billing and User Charges Information Regulations Règlement concernant les renseignements sur la surfacturation et les frais modéra-
teurs
Types of Information Genre de renseignements
provide the Minister with information of the following fournisse les renseignements suivants sur les montants
types with respect to user charges in the province in a fis- des frais modérateurs imposés dans la province au cours
cal year: d’un exercice :
(a) an estimate of the aggregate amount that, at the a) une estimation du montant total, à la date de l’esti-
time the estimate is made, is expected to be charged in mation, des frais modérateurs visés à l’article 19 de la
respect of user charges to which section 19 of the Act Loi, accompagnée d’une explication de la façon dont
applies, including an explanation regarding the cette estimation a été obtenue;
method of determination of the estimate; and
b) un état financier indiquant le montant total des
(b) a financial statement showing the aggregate frais modérateurs visés à l’article 19 de la Loi effective-
amount actually charged in respect of user charges to ment imposés dans la province, accompagné d’une ex-
which section 19 of the Act applies, including an expla- plication de la façon dont le bilan a été établi.
nation regarding the method of determination of the
aggregate amount.
Times and Manner of Filing Communication de

Information renseignements
5 (1) The government of a province shall provide the 5 (1) Le gouvernement d’une province doit communi-
Minister with such information, of the types prescribed quer au ministre les renseignements visés aux articles 3
by sections 3 and 4, as the Minister may reasonably re- et 4, dont le ministre peut normalement avoir besoin, se-
quire, at the following times: lon l’échéancier suivant :
(a) in respect of the estimates referred to in para- a) pour les estimations visées aux alinéas 3a) et 4a),
graphs 3(a) and 4(a), before April 1 of the fiscal year to avant le 1er avril de l’exercice visé par ces estimations;
which they relate; and
b) pour les états financiers visés aux alinéas 3b) et
(b) in respect of the financial statements referred to in 4b), avant le seizième jour du vingt et unième mois qui
paragraphs 3(b) and 4(b), before the sixteenth day of suit la fin de l’exercice visé par ces états.
the twenty-first month following the end of the fiscal
year to which they relate.
(2) The government of a province may, at its discretion, (2) Le gouvernement d’une province peut, à sa discré-
provide the Minister with adjustments to the estimates tion, fournir au ministre des ajustements aux estimations
referred to in paragraphs 3(a) and 4(a) before Febru- prévues aux alinéas 3a) et 4a), avant le 16 février de l’an-
ary 16 of the fiscal year to which they relate. née financière visée par ces estimations.
(3) The information referred to in subsections (1) and (2) (3) Les renseignements visés aux paragraphes (1) et (2)
shall be transmitted to the Minister by the most practical doivent être expédiés au ministre par le moyen de com-
means of communication. munication le plus pratique.
162

ANNEX B | POLICY INTERPRETATION LETTERS
ANN EX B
POLICY INTERPRETATION LETTERS “hospital” contained in the Canada Health Act, in-
cludes any facility that provides acute, rehabilitative or
There are two key policy statements that clarify the chronic care. Thus, when a provincial or territorial health
federal position on the Canada Health Act. These state- insurance plan pays the physician fee for a medically
ments have been made in the form of ministerial letters necessary service delivered at a private clinic, it must
from former Federal Health Ministers to their provincial also pay the facility fee or face a deduction from federal
and territorial counterparts. transfer payments.
Epp Letter [Following is the text of the letter sent on June 18,
In June 1985, approximately one year following the 1985 to all provincial and territorial Ministers of
passage of the Canada Health Act in Parliament, then- Health by the Honourable Jake Epp, Federal Minister
Federal Health Minister Jake Epp wrote to his provincial of Health and Welfare. (Note: Minister Epp sent the
and territorial counterparts to set out and confirm the French equivalent of this letter to Quebec on July 15,
federal position on the interpretation and implementation 1985.) ]
of the Canada Health Act.
Minister Epp’s letter followed several months of consul-

tation with his provincial and territorial counterparts. The
letter sets forth statements of federal policy intent which
clarify the criteria, conditions and regulatory provisions of
the Canada Health Act. These clarifications have been used
by the federal government in the assessment and interpre-
tation of compliance with the Act. The Epp letter remains
an important reference for interpretation of the Act.
Federal Policy on Private Clinics

Between February 1994 and December 1994, a series
of seven federal/provincial/territorial meetings dealing
wholly or in part with private clinics took place. At issue
was the growth of private clinics providing medically
necessary services funded partially by the public system
and partially by patients and its impact on Canada’s uni-
versal, publicly funded health care system.
At the September 1994 Federal/Provincial/Territorial

Health Ministers Meeting in Halifax, all Ministers of
Health present, with the exception of Alberta’s Health
Minister, agreed to “take whatever steps are required to
regulate the development of private clinics in Canada.”
Diane Marleau, the Federal Minister of Health at the

time, wrote to all provincial and territorial Ministers of
Health on January 6, 1995 to announce the new Federal
Policy on Private Clinics. The Minister’s letter provided
the federal interpretation of the Canada Health Act as
it relates to the issue of facility fees charged directly
to patients receiving medically necessary services at
private clinics. The letter stated that the definition of

June 18, 1985

OTTAWA, K1A 0K9
Dear Minister:
Having consulted with all provincial and territorial Ministers of Health over the past several months, both individually
and at the meeting in Winnipeg on May 16 and 17, I would like to confirm for you my intentions regarding the inter-
pretation and implementation of the Canada Health Act. I would particularly appreciate if you could provide me with
a written indication of your views on the attached proposals for regulations in order that I may act to have these
officially put in place as soon as conveniently possible. Also, I will write to you further with regard to the material
I will need to prepare the required annual report to Parliament.
As indicated at our meeting in Winnipeg, I intend to honour and respect provincial jurisdiction and authority in matters
pertaining to health and the provision of health care services. I am persuaded, by conviction and experience, that
more can be achieved through harmony and collaboration than through discord and confrontation.
With regard to the Canada Health Act, I can only conclude from our discussions that we together share a public
trust and are mutually and equally committed to the maintenance and improvement of a universal, comprehensive,
accessible and portable health insurance system, operated under public auspices for the benefit of all residents
of Canada.
Our discussions have reinforced my belief that you require sufficient flexibility and administrative versatility to operate
and administer your health care insurance plans. You know far better than I ever can, the needs and priorities of
your residents, in light of geographic and economic considerations. Moreover, it is essential that provinces have the
freedom to exercise their primary responsibility for the provision of personal health care services.
At the same time, I have come away from our discussions sensing a desire to sustain a positive federal involve-
ment 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
164
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 ser-
vices 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 effi-
ciently 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 inter-
fere 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 popu-
lation group with respect to charges for, or necessary use of, insured services. At the same time, the Act accents
a partnership between the providers of insured services and provincial plans, requiring that provincial plans have in
place reasonable systems of payment or compensation for their medical practitioners in order to ensure reasonable
access to users. I want to emphasize my intention to respect provincial prerogatives regarding the organization,
licensing, supply, distribution of health manpower, as well as the resource allocation and priorities for health services.
I want to assure you that the reasonable access provision will not be used to intervene or interfere directly in
matters such as the physical and geographic availability of services or provincial governance of the institutions and
professions that provide insured services. Inevitably, major issues or concerns regarding access to health care
services will come to my attention. I want to assure you that my Ministry will work through and with provincial/
territorial Ministers in addressing such matters.
My aim in communicating my intentions with respect to the criteria in the Canada Health Act is to allow us to work
together in developing our national health insurance scheme. Through continuing dialogue, open and willing
exchange of information and mutually understood rules of the road, I believe that we can implement the Canada
Health Act without acrimony and conflict. It is my preference that provincial/territorial Ministers themselves be
given an opportunity to interpret and apply the criteria of the Canada Health Act to their respective health care
insurance plans. At the same time, I believe that all provincial/territorial Health Ministers understand and respect
my accountability to the Parliament of Canada, including an annual report on the operation of provincial health care
insurance plans with regard to these fundamental criteria.
Conditions
This leads me to the conditions related to the recognition of federal contributions and to the provision of information,
both of which may be specified in regulations. In these matters, I will be guided by the following principles:
1. to make as few regulations as possible and only if absolutely necessary;
2. to rely on the goodwill of Ministers to afford appropriate recognition of Canada’s role and contribution and to
provide necessary information voluntarily for purposes of administering the Act and reporting to Parliament;
166
3. to employ consultation processes and mutually beneficial information exchanges as the preferred ways and
means of implementing and administering the Canada Health Act;
4. to use existing means of exchanging information of mutual benefit to all our governments.
Regarding recognition by provincial/territorial governments of federal health contributions, I am satisfied that we

can easily agree on appropriate recognition, in the normal course of events. The best form of recognition in my view
is the demonstration to the public that as Ministers of Health we are working together in the interests of the tax-
payer 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 infor-
mation systems in such areas as morbidity, mortality, health status, health services operations, utilization, health
care costs and financing.
I firmly believe that the federal government need not regulate these matters. Accordingly, I do not intend to use the
regulatory authority respecting information requirements under the Canada Health Act to expand, modify or change
these broad-based data systems and exchanges. In order to keep information flows related to the Canada Health
Act to an economical minimum, I see only two specific and essential information transfer mechanisms:
1. estimates and statements on extra-billing and user charges;
2. an annual provincial statement (perhaps in the form of a letter to me) to be submitted approximately six months
after the completion of each fiscal year, describing the respective provincial health care insurance plan’s operations
as they relate to the criteria and conditions of the Canada Health Act.
Concerning Item 1 above, I propose to put in place on-going regulations that are identical in content to those that
have been accepted for 1985-86. Draft regulations are attached as Annex I. To assist with the preparation of the “annual
provincial statement” referred to in Item 2 above, I have developed the general guidelines attached as Annex II.
Beyond these specific exchanges, I am confident that voluntary, mutually beneficial exchange of such subjects as
Acts, regulations and program descriptions will continue.
One matter brought up in the course of our earlier meetings, is the question of whether estimates or deductions
of user charges and extra-billing should be based on “amounts charged” or “amounts collected”. The Act clearly
states that deductions are to be based on amounts charged. However, with respect to user fees, certain provincial
plans appear to pay these charges indirectly on behalf of certain individuals. Where a provincial plan demonstrates
that it reimburses providers for amounts charged but not collected, say in respect of social assistance recipients or
unpaid accounts, consideration will be given to adjusting estimates/deductions accordingly.
I want to emphasize that where a provincial plan does authorize user charges, the entire scheme must be consistent
with the intent of the reasonable accessibility criterion as set forth [in this letter].
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 chal-
lenges 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
[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 admin-
istration, 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 safe-
guard 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 im-
portant 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, out-
side 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 vio-
late 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.
168
The formal basis for my position on facility fees is twofold. The first is a matter of policy. In the context of contem-
porary 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 intend-
ed 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 facili-
ty fees for medically necessary services. As I do not wish to cause undue hardship to those provinces, I will com-
mence 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
170
ANNEX C | DISPUTE AVOIDANCE AND RESOLUTION PROCESS UNDER THE CANADA HEALTH ACT
AN NE X C
DISPUTE AVOIDANCE AND
RESOLUTION PROCESS UNDER
THE CANADA HEALTH ACT
In April 2002, the Honourable A. Anne McLellan outlined
in a letter to her provincial and territorial counterparts a
Canada Health Act Dispute Avoidance and Resolution
process, which was agreed to by provinces and territories,
except Quebec. The process meets federal and provincial/
territorial interests of avoiding disputes related to the in-
terpretation of the principles of the Canada Health Act,
and when this is not possible, resolving disputes in a fair,
transparent and timely manner.
The process includes the dispute avoidance activities

of government-to-government information exchange;
discussions and clarification of issues, as they arise;
active participation of governments in ad hoc federal/
provincial/territorial committees on Canada Health Act
issues; and Canada Health Act advance assessments,
upon request.
Where dispute avoidance activities prove unsuccessful,

dispute resolution activities may be initiated, beginning
with government-to-government fact-finding and nego-
tiations. If these are unsuccessful, either Minister of
Health involved may refer the issues to a third party
panel to undertake fact-finding and provide advice and
recommendations.
The Federal Minister of Health has the final authority

to interpret and enforce the Canada Health Act. In decid-
ing whether to invoke the non-compliance provisions of
the Act, the Minister will take the panel’s report into
consideration.
In September 2004, the agreement reached between

the provinces and territories in 2002 was formalized by
First Ministers, thereby reaffirming their commitment
to use the Canada Health Act Dispute Avoidance and
Resolution process to deal with Canada Health Act
interpretation issues.
On the following pages you will find the full text of

Minister McLellan’s Letter to the Honourable Gary Mar,
as well as a fact sheet on the Canada Health Act Dispute
Avoidance and Resolution Process.

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 be-
low. I believe this approach will enable us to avoid and resolve issues related to the interpretation of the principles
of the Canada Health Act in a fair, transparent and timely manner.
Dispute Avoidance
The best way to resolve a dispute is to prevent it from occurring in the first place. The federal government has rarely
resorted to penalties and only when all other efforts to resolve the issue have proven unsuccessful. Dispute avoid-
ance has worked for us in the past and it can serve our shared interests in the future. Therefore, it is important that
governments continue to participate actively in ad hoc federal/provincial/territorial committees on Canada Health Act
issues and undertake government-to-government information exchange, discussions and clarification on issues as
they arise.
Moreover, Health Canada commits to provide advance assessments to any province or territory upon request.
Dispute Resolution
Where the dispute avoidance activities between the federal government and a provincial or territorial government
prove unsuccessful, either Minister of Health involved may initiate dispute resolution by writing to his or her coun-
terpart. 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 pro-
cess, jointly:
• collect and share all relevant facts;
• prepare a fact-finding report;
• negotiate to resolve the issue in dispute; and
• prepare a report on how the issue was resolved.
If, however, there is no agreement on the facts, or if negotiations fail to resolve the issue, any Minister of Health
involved in the dispute may initiate the process to refer the issue to a third party panel by writing to his or her
counterpart. Within 30 days of the date of that letter, a panel will be struck. The panel will be composed of one
provincial/territorial appointee and one federal appointee who, together, will select a chairperson. The panel will
assess the issue in dispute in accordance with the provisions of the Canada Health Act, will undertake fact-finding
and provide advice and recommendations. It will then report to the governments involved on the issue within 60
days of appointment.
172
The Minister of Health for Canada has the final authority to interpret and enforce the Canada Health Act. In deciding
whether to invoke the non-compliance provisions of the Act, the Minister of Health for Canada will take the panel’s
report into consideration.
Public Reporting
Governments will report publicly on Canada Health Act dispute avoidance and resolution activities, including any
panel report.
I believe that the Government of Canada has followed through on its September 2000 Health Agreement commit-
ments 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 straight-
forward. 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

FACT SHEET: CANADA HEALTH • The panel will assess the issue in dispute in accor-
dance with the provisions of the Canada Health Act,
ACT DISPUTE AVOIDANCE AND will undertake fact- finding and provide advice and
RESOLUTION PROCESS recommendations.
Scope • The panel will then report to the governments involved

The provisions described apply to the interpretation of on the issue within 60 days of appointment.
the principles of the Canada Health Act.
The Minister of Health for Canada has the final authority to
Dispute Avoidance interpret and enforce the Canada Health Act. In deciding
To avoid and prevent disputes, governments will whether to invoke the non-compliance provisions of the
continue to: Act, the Minister of Health for Canada will take the panel’s
report into consideration.
• participate actively in ad hoc federal/provincial/territorial
committees on Canada Health Act issues; and Public Reporting
Governments will report publicly on Canada Health Act
•
undertake government-to-government information dispute avoidance and resolution activities, including
exchange, discussions and clarification on issues as any panel report.
they arise.
Review
Health Canada commits to provide advance assess- Should adjustments be necessary in the future, the
ments to any province or territory upon request. Minister of Health for Canada commits to review the
process with Provincial and Territorial Ministers of Health.
Dispute Resolution
Where the dispute avoidance activities between the
federal government and a provincial or territorial govern-
ment 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:
• collect and share all relevant facts;
• prepare a fact-finding report;
• negotiate to resolve the issue in dispute; and
• prepare a report on how the issue was resolved.
If however, there is no agreement on the facts, or if

negotiations fail to resolve the issue, any Minister of
Health involved in the dispute may initiate the process
to refer the issue to a third party panel by writing to his
or her counterpart.
• Within 30 days of the date of that letter, a panel will be

struck. The panel will be composed of one provincial/
territorial appointee and one federal appointee, who
together will select a chairperson.
174
CONTACT INFORMATION FOR Manitoba
Manitoba Health, Seniors and Active Living
PROVINCIAL AND TERRITORIAL 300 Carlton Street
DEPARTMENTS OF HEALTH Winnipeg, MB R3B 3M9
1-800-392-1207
www.manitoba.ca/health
Newfoundland and Labrador Saskatchewan
Department of Health and Community Services Saskatchewan Health
Confederation Building 3475 Albert Street
P.O. Box 8700 Regina, SK S4S 6X6
St.John’s, NL A1B 4J6 1-800-667-7766
(709) 729-5021 Email info@health.gov.sk.ca
www.gov.nl.ca/health www.saskatchewan.ca
Prince Edward Island Alberta
Department of Health and Wellness Alberta Health
P.O. Box 2000 P.O. Box 1360, Station Main
Charlottetown, PE C1A 7N8 Edmonton, AB T5J 2N3
(902) 368-6414 (780) 427-7164
www.gov.pe.ca/health www.health.alberta.ca
Nova Scotia British Columbia
Department of Health and Wellness Ministry of Health
1894 Barrington Street 1515 Blanshard Street
P.O. Box 488 PO Box 9639 Stn Prov Govt
Halifax, NS B3J 2R8 Victoria, BC, V8W 9P1
(902) 424-5818 Toll free in B.C.: 1-800-663-7867
1-800-387-6665 (toll-free in Nova Scotia) In Victoria: 250-387-6121
1-800-670-8888 (TTY/TDD) www.gov.bc.ca/health
www.novascotia.ca/DHW
Yukon
New Brunswick Department of Health and Social Services
Department of Health Insured Health Services Branch H-2
P.O. Box 5100 P.O. Box 2703
Fredericton, NB E3B 5G8 Whitehorse, YT Y1A 2C6
(506) 457-4800 1-867-667-5202
www.gnb.ca/health www.hss.gov.yk.ca
Quebec Northwest Territories
Ministry of Health and Social Services Department of Health and Social Services
1075 Sainte-Foy Road P.O. Box 1320
Québec, QC G1S 2M1 Yellowknife, NWT X1A 2L9
(418) 266-7005 1-800-661-0830 or 1-867-777-7413 ext 49051
www.msss.gouv.qc.ca www.hss.gov.nt.ca
Ontario Nunavut
Ministry of Health and Long-Term Care Department of Health
10th Floor, Hepburn Block P.O. Box 1000, Station 1000
80 Grosvenor Street Iqaluit, NU X0A 0H0
Toronto, ON M7A 1R3 1-867-975-5700
1-800-268-1153 www.gov.nu.ca/health
www.health.gov.on.ca
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CANADA HEALTH ACT

Public Administration / Comprehensiveness / Universality / Portability / Accessibility

Tel.: 613-957-2991 Manitoba Health, Seniors and Active Living

PDF Cat.: H1-4E-PDF

CHAPTER 1: Canada Health Act Overview 7

CHAPTER 2: Administration and Compliance 15

CHAPTER 3: Provincial and Territorial Health Care Insurance Plans in 2015-2016 22

Newfoundland and Labrador 24

Prince Edward Island 34

British Columbia 105

Northwest Territories 126

ANNEX B: Policy Interpretation Letters 163

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 3

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 5

On an annual basis, the Federal Minister of Health is

The Canada Health Act is Canada’s federal health care

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 7

They are: or territory of residence. It is the responsibility of residents

THE CONDITIONS government to make regulations for administering the

Regulations (section 22) Discretionary Penalty Provisions

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 9

conditions of the Act is subject to a discretionary penalty. Excluded Persons

In the mid-1950s in response to public pressures, the

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 11

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 13

Following up on the 2007 legislation for a transition to an

Additional information on federal-provincial-territorial

Administration • informing the Federal Minister of Health of possible

THE CANADA HEALTH ACT DIVISION INTERPROVINCIAL HEALTH

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 15

During the reporting period, IHIACC added abortion COMPLIANCE ISSUES

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 17

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 19

DEDUCTIONS AND REFUNDS TO CHST/CHT CASH CONTRIBUTIONS IN ACCORDANCE

Understanding This Chart

WITH THE CANADA HEALTH ACT SINCE 1994–1995 (IN DOLLARS)

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 21

PROVINCIAL AND TERRITORIAL HEALTH

• a narrative description of the provincial or territorial

CARE INSURANCE PLANS IN 2015-2016

Registered Persons: Registered persons are the number

Insured Hospital Services within Own Province or

Insured Hospital Services Provided to Residents in

Insured Hospital Services Provided Outside Canada:

Insured Physician Services within Own Province or

Insured Physician Services Provided to Residents in

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 23

1.2 Reporting Relationship

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 25

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 27

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 29

5.0 ACCESSIBILITY Through the actions of the Provincial Emergency

5.3 Payments to Hospitals

Throughout the fiscal year, the RHAs forwarded

CANADA HEALTH ACT ANNUAL REPORT 2015 -2016 31

INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY

PRIVATE FOR-PROFIT FACILITIES

INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS

INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA

Administration • informing the Federal Minister of Health of possible

• a narrative description of the provincial or territorial

1 Excludes inactive physicians. Total salaried and fee-for-service.

• perform such other duties as the Minister may direct.

Generally included as insured surgical-dental services •

Uninsured hospital services include: • provision of travel vaccines;

• services such as gastric bypass for morbid obesity, •

3 Total services includes block funded dentists.

Code Service Description • correction of inverted nipple;

1 There are no private for-profit facilities operating in New Brunswick.