Canada Health Act

CANADA HEALTH ACT
CANADA HEALTH ACT

Public Administration Public Administration
Accessibility Accessibility
Universality Universality
ANNUAL REPORT 2014–2015

Comprehensiveness Comprehensiveness
Portability Portability
ANNUAL 2014
REPORT 2015
Health Canada is the federal department responsible for helping the people of Canada maintain
and improve their health. Health Canada is committed to improving the lives of all of Canada’s
people and to making this country’s population among the healthiest in the world as measured
by longevity, lifestyle and effective use of the public health care system.
Published by authority of the Minister of Health.
Canada Health Act – Annual Report 2014–2015

is available on Internet at the following address:
http://www.hc-sc.gc.ca/hcs-sss/pubs/cha-lcs/index-eng.php
Également disponible en français sous le titre:

Loi canadienne sur la santé – Rapport Annuel 2014-2015
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ACKNOWLEDGEMENTS
Health Canada would like to acknowledge the work and effort that went into producing this Annual Report. It is through the
dedication and timely commitment of the following departments of health and their staff that we are able to bring you this report
on the administration and operation of the Canada Health Act:
Newfoundland and Labrador Department of Health and Community Services
Prince Edward Island Department of Health and Wellness
Nova Scotia Department of Health and Wellness
New Brunswick Department of Health
Quebec Ministry of Health and Social Services
Ontario Ministry of Health and Long-Term Care
Manitoba Health, Healthy Living and Seniors
Saskatchewan Health
Alberta Health
British Columbia Ministry of Health
Yukon Health and Social Services
Northwest Territories Department of Health and Social Services
Nunavut Department of Health
We also greatly appreciate the extensive work effort that was put into this report by our production team: the desktop publishing
company, the translators, editors and concordance experts, printers and staff of Health Canada at headquarters and in the
regional offices.
CANADA HEALTH ACT ANNUAL REPORT 2014–2015 i

ii CANADA HEALTH ACT ANNUAL REPORT 2014–2015
TABLE OF CONTENTS
Acknowledgements___________________________________________________________________________________________ i
Introduction_________________________________________________________________________________________________1
Chapter 1 — Canada Health Act Overview_________________________________________________________________________3
Chapter 2 — Administration and Compliance______________________________________________________________________11
Chapter 3 — Provincial and Territorial Health Care Insurance Plans in 2013–2014________________________________________19
Newfoundland and Labrador________________________________________________________________________21
Prince Edward Island______________________________________________________________________________31
Nova Scotia______________________________________________________________________________________39
New Brunswick___________________________________________________________________________________49
Quebec_________________________________________________________________________________________ 59
Ontario_________________________________________________________________________________________63
Manitoba________________________________________________________________________________________75
Saskatchewan_____________________________________________________________________________________85
Alberta__________________________________________________________________________________________95
British Columbia_________________________________________________________________________________103
Yukon__________________________________________________________________________________________115
Northwest Territories____________________________________________________________________________ 125
Nunavut________________________________________________________________________________________133
Annex A — Canada Health Act and Extra-Billing and User Charges Information Regulations____________________________141
Annex B — Policy Interpretation Letters________________________________________________________________________163
Annex C — Dispute Avoidance and Resolution Process under the Canada Health Act___________________________________171
Contact Information for Provincial and Territorial Departments of Health__________________________________inside back cover
CANADA HEALTH ACT ANNUAL REPORT 2014–2015 iii

iv CANADA HEALTH ACT ANNUAL REPORT 2014–2015
INTRODUCTION
Canada has a predominantly publicly financed and adminis- primary jurisdiction in the administration and delivery of
tered health care system. The Canadian health insurance system health care services. This includes setting their own priorities,
is achieved through 13 interlocking provincial and territorial administering their health care budgets and managing their
health insurance plans, and is designed to ensure that all own resources. The federal government, under the Canada
eligible residents of Canadian provinces and territories have Health Act, sets out the criteria and conditions that must be
reasonable access to medically necessary hospital and physician satisfied by the provincial and territorial health insurance plans
services on a prepaid basis, without charges related to the for provinces and territories to qualify for their full share of the
provision of insured health services. cash contribution available to them under the federal Canada
Health Transfer.
The Canadian health insurance system evolved into its present
form over more than six decades. Saskatchewan was the first On an annual basis, the federal Minister of Health is required
province to establish universal, public hospital insurance in to report to Parliament on the administration and operation of
1947 and, ten years later, the Government of Canada passed the Canada Health Act, as set out in section 23 of the Act. The
the Hospital Insurance and Diagnostic Services Act (1957), to vehicle for so doing is the Canada Health Act Annual Report.
share in the cost of these services with the provinces and While the principal and intended audience for the annual
territories. By 1961, all the provinces and territories had public report is Parliamentarians, it is a public document that offers
insurance plans that provided universal access to hospital a comprehensive description of insured health services in each
services. Saskatchewan again pioneered by providing insurance of the provinces and territories. The annual report is structured
for physician services, beginning in 1962. The Government of to address the mandated reporting requirements of the Act; as
Canada enacted the Medical Care Act in 1966 to cost-share the such, its scope does not extend to commenting on the status of
provision of insured physician services with the provinces and the Canadian health care system as a whole.
territories. By 1972, all provincial and territorial plans had been
extended to include physician services. Provincial and territorial health care insurance plans generally
respect the criteria and conditions of the Canada Health Act
In 1979, at the request of the federal government, Justice and many exceed the requirements of the Act. However,
Emmett Hall undertook a review of the state of health services when instances of possible non-compliance with the Act
in Canada. In his report, he affirmed that health care services arise, Health Canada’s approach to the administration of the
in Canada ranked among the best in the world, but warned that Act emphasizes transparency, consultation and dialogue with
extra-billing by doctors and user charges levied by hospitals provincial and territorial health care ministries. The application
were creating a two-tiered system that threatened the universal of financial penalties through deductions under the Canada
accessibility of care. This report, and the national debate it gen- Health Transfer is considered only as a last resort when all
erated, led to the enactment of the Canada Health Act in 1984. other options to resolve an issue collaboratively have been
exhausted. Pursuant to the commitment made by premiers
The Canada Health Act is Canada’s federal health insurance under the 1999 Social Union Framework Agreement, federal,
legislation and defines the national principles that govern provincial and territorial governments (except Quebec) agreed
the Canadian health insurance system, namely, public admin- through an exchange of letters, in April 2002, to a Canada
istration, comprehensiveness, universality, portability and Health Act Dispute Avoidance and Resolution (DAR) process.
accessibility. These principles reflect the underlying Canadian The DAR process was formalized in the First Ministers’ 2004
values of equity and solidarity. Accord. Although the DAR process includes dispute resolution
provisions, the federal Minister of Health retains the final
The roles and responsibilities for Canada’s health care system
authority to interpret and enforce the Canada Health Act.
are shared between the federal, provincial and territorial
governments. The provincial and territorial governments have
CANADA HEALTH ACT ANNUAL REPORT 2014–2015 1

2 CANADA HEALTH ACT ANNUAL REPORT 2014–2015
CHAPTER 1
CANADA HEALTH ACT OVERVIEW
This section describes the Canada Health Act, its requirements, Persons excluded under the Act include serving members of
key definitions, regulations and regulatory provisions, letters by the Canadian Forces and inmates of federal penitentiaries.
former federal Ministers of Health Jake Epp and Diane Marleau
to their provincial and territorial counterparts that are used in Insured health services are medically necessary hospital,
the interpretation and application of the Act, and the letter from physician and surgical-dental services (performed by a dentist
former federal Minister, A. Anne McLellan, to her provincial in a hospital, where a hospital is required for the proper
and territorial counterparts on the Canada Health Act Dispute performance of the procedure) provided to insured persons.
Avoidance and Resolution process. A history of the evolution
Insured hospital services are defined under the Act and
of federal health care transfers follows.
include medically necessary in- and out-patient services such
as accommodation and meals at the standard or public ward
WHAT IS THE CANADA level and preferred accommodation if medically required;
nursing service; laboratory, radiological and other diagnostic
HEALTH ACT? procedures, together with the necessary interpretations; drugs,
biologicals and related preparations when administered in the
The Canada Health Act is Canada’s federal legislation for hospital; use of operating room, case room and anaesthetic
publicly funded health care insurance. The Act sets out the facilities, including necessary equipment and supplies; medical
primary objective of Canadian health care policy, which is and surgical equipment and supplies; use of radiotherapy
“to protect, promote and restore the physical and mental well- facilities; use of physiotherapy facilities; and services provided
being of residents of Canada and to facilitate reasonable access by persons who receive remuneration therefor from the
to health services without financial or other barriers.” hospital, but does not include services that are excluded
by the regulations.
The Act establishes criteria and conditions related to insured
health services and extended health care services that the Insured physician services are defined under the Act as
provinces and territories must fulfill to receive the full federal “medically required services rendered by medical practitioners.”
cash contribution under the Canada Health Transfer (CHT). Medically required physician services are generally determined
by the provincial or territorial health insurance plan, in
The aim of the Act is to ensure that all eligible residents of conjunction with the medical profession.
Canadian provinces and territories have reasonable access to
medically necessary hospital and physician services on a prepaid Insured surgical-dental services are services provided by a
basis, without charges related to the provision of insured dentist in a hospital, where a hospital setting is required to
health services. properly perform the procedure.
Extended health care services, as defined in the Act, are

Key Definitions Under the Canada Health Act certain aspects of long-term residential care (nursing home
intermediate care and adult residential care services), and the
Insured persons are eligible residents of a province or territory. health aspects of home care and ambulatory care services.
A resident of a province is defined in the Act as “a person
lawfully entitled to be or to remain in Canada who makes his
home and is ordinarily present in the province, but does not
include a tourist, a transient or a visitor to the province.”

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

The Conditions User Charges (section 19)

1. Information (section 13(a)) The Act defines user charges as any charge for an insured
health service, other than extra-billing. For example, if patients
The provincial and territorial governments are required to were charged a facility fee for the non-physician (i.e., hospital)
provide information to the federal Minister of Health as services provided in conjunction with a physician service that is
prescribed by regulations under the Act. insured under the provincial health insurance plan at a clinic,
that fee would be considered a user charge. User charges are
2. Recognition (section 13(b)) not permitted under the Act because, as is the case with extra-
billing, they constitute a barrier or impediment to access.
The provincial and territorial governments are required to
recognize the federal financial contributions toward both
insured and extended health care services. OTHER ELEMENTS OF THE ACT
Extra-billing and User Charges Regulations (section 22)
The provisions of the Canada Health Act pertaining to extra- Section 22 of the Canada Health Act enables the federal
billing and user charges for insured health services in a government to make regulations for administering the Act
province or territory are outlined in sections 18 to 21. If it in the following areas:
can be confirmed that either extra-billing or user charges
exist in a province or territory, a mandatory deduction from ■■ defining the services included in the Act’s definition of
the federal cash transfer to that province or territory is “extended health care services,” e.g., nursing home care or
required under the Act. The amount of such a deduction for home care;
a fiscal year is determined by the federal Minister of Health. ■■ prescribing which services are excluded from hospital services;
This can be based on information provided by the province
or territory in accordance with the Extra-billing and User ■■ prescribing the types of information that the federal
Charges Information Regulations (described below). Section Minister of Health may reasonably require, as well as the
20 of the Act requires the Minister to make an estimate of the format and submission deadline for the information; and
amount of extra-billing and user charges where information ■■ prescribing how provinces and territories are required
is not provided in accordance with the regulations. This to recognize the CHT in their documents, advertising
process requires the Minister to consult with the province or promotional materials.
or territory concerned.
To date, the only regulations in force under the Act are the
Extra-billing and User Charges Information Regulations.
Extra-billing (section 18) These regulations require the provinces and territories to
annually report to Health Canada amounts of extra-billing
Under the Act, extra-billing is defined as the billing for an and user charges levied. A copy of these regulations is provided
insured health service rendered to an insured person by a in Annex A.
medical practitioner or a dentist (i.e., a dentist providing
insured surgical-dental services in a hospital setting) in an
amount in addition to any amount paid or to be paid for that Penalty Provisions of the Canada Health Act
service by the health care insurance plan of a province or
territory. For example, if a physician was to charge a patient Mandatory Penalty Provisions
any amount for an office visit that is insured by the provincial
or territorial health insurance plan, the amount charged would Under the Act, provinces and territories that allow extra-billing
constitute extra-billing. Extra-billing is seen as a barrier or and user charges are subject to mandatory dollar-for-dollar
impediment for people seeking medical care, and is therefore deductions from the federal transfer payments under the CHT.
also contrary to the accessibility criterion. In plain terms, this means that when it has been determined
that a province or territory has allowed $500,000 in extra-
billing by physicians, the federal cash contribution to that
province or territory will be reduced by that same amount.

Discretionary Penalty Provisions Excluded Persons

Non-compliance with one of the five criteria or two conditions The Canada Health Act definition of “insured person” excludes
of the Act is subject to a discretionary penalty. The amount of members of the Canadian Forces and persons serving a term of
any deduction from federal transfer payments under the CHT imprisonment within a federal penitentiary. The Government
is based on the magnitude of the non-compliance. of Canada provides coverage to these groups through separate
federal programs.
The Canada Health Act sets out a consultation process that must
be undertaken with the province or territory before discretionary The exclusion of these persons from insured health service
penalties can be levied. To date, the discretionary penalty coverage predates the adoption of the Act and is not intended
provisions of the Act have not been applied. to constitute differences in access to publicly insured health care.
There is a Frequently Asked Questions link on Health Canada’s

EXCLUDED SERVICES web-site to address common concerns that Canadians might
have about Canada’s publicly funded health insurance plans.
AND PERSONS
See: http://hc-sc.gc.ca/hcs-sss/medi-assur/faq-eng.php
Although the Canada Health Act requires that insured health
services be provided to insured persons in a manner that is
consistent with the criteria and conditions set out in the Act,
not all Canadian residents or health services fall under the
POLICY INTERPRETATION
scope of the Act. LETTERS
There are two key policy statements that clarify the federal
Excluded Services position on the Canada Health Act. These statements were made
in the form of ministerial letters from former federal Ministers
A number of services provided by hospitals and physicians are of Health to their provincial and territorial counterparts. Both
not considered medically necessary, and thus are not insured letters are reproduced in Annex B of this report.
under provincial and territorial health insurance legislation.
Uninsured hospital services for which patients may be charged
include preferred hospital accommodation unless prescribed Epp Letter
by a physician or when standard ward level accommodation
is unavailable, private duty nursing services and the provision In June 1985, approximately one year following the passage of
of telephones and televisions. Uninsured physician services the Canada Health Act in Parliament, federal Minister of Health
for which patients may be charged include telephone advice; and Welfare Jake Epp wrote to his provincial and territorial
the provision of medical certificates required for work, school, counterparts to set out and confirm the federal position on the
insurance purposes and fitness clubs; testimony in court; and interpretation and implementation of the Act
cosmetic services.
Minister Epp’s letter followed several months of consultation
In addition, the definition of “insured health services” excludes with his provincial and territorial counterparts. The letter
services to persons provided under any other Act of Parliament sets forth statements of federal policy intent that clarify the
(e.g., inmates of federal penitentiaries) or under the workers’ Act’s criteria, conditions and regulatory provisions. These
compensation legislation of a province or territory. clarifications have been used by the federal government in
assessing and interpreting compliance with the Act. The Epp
In addition to the medically necessary hospital and physician letter remains an important reference for interpreting the Act.
services covered by the Canada Health Act, provinces and
territories also provide a range of other programs and services.
These are provided at provincial and territorial discretion, on Marleau Letter — Federal Policy on
their own terms and conditions, and vary from one province or Private Clinics
territory to another. Additional services that may be provided
include pharmacare, ambulance services and optometric Between February 1994 and December 1994, a series of seven
services. The additional services provided by provinces and federal/provincial/territorial meetings dealing wholly, or in
territories are often targeted to specific population groups part, with private clinics took place. At issue was the growth
(e.g., children, seniors or social assistance recipients), and may of private clinics providing medically necessary services funded
be partially or fully covered by the province or territory. partially by the public system and partially by patients, and
their impact on Canada’s universal, publicly funded health
care system.

At the September 1994 federal/provincial/territorial meeting

of health ministers in Halifax, all ministers of health present,
EVOLUTION OF FEDERAL
with the exception of Alberta’s health minister, agreed to HEALTH CARE TRANSFERS
“take whatever steps are required to regulate the development
of private clinics in Canada.”
Grants To Help Establish Programs and
Diane Marleau, the federal Minister of Health at the time,
wrote to all provincial and territorial ministers of health on Cost-Sharing
January 6, 1995, to announce the new Federal Policy on Private
Federal support for provincial health care goes back to the
Clinics. The Minister’s letter provided the federal interpretation
late 1940s when the National Health Grants were created.
of the Canada Health Act as it relates to the issue of facility
These grants were considered to be essential building blocks
fees charged directly to patients receiving medically necessary
of a national health care system. While the grants were
services at private clinics. The letter stated that the definition
mainly used to build up the Canadian hospital infrastructure,
of “hospital” contained in the Act includes any public facility
they also supported initiatives in areas such as professional
that provides acute, rehabilitative or chronic care. Thus, when a
training, public health research, tuberculosis control and
provincial or territorial health insurance plan pays the physician
cancer treatment. By the mid-1960s, the grants available
fee for a medically necessary service delivered at a private clinic,
to the provinces totalled more than $60 million annually.
it must also pay the facility fee or face a deduction from federal
transfer payments. In the mid-1950s in response to public pressures, the
federal government agreed to provide financial assistance to
provinces to help them establish health insurance programs.
DISPUTE AVOIDANCE AND In January 1956, the federal government placed concrete
RESOLUTION PROCESS proposals before the provinces to inaugurate a phased health
insurance program, with priority given to hospital insurance
In April 2002, federal Minister of Health A. Anne McLellan and diagnostic services. Discussions on these proposals led to
outlined in a letter to her provincial and territorial counterparts the adoption of the Hospital Insurance and Diagnostic Services Act
a Canada Health Act Dispute Avoidance and Resolution (HIDSA) in 1957. The implementation of the HIDSA started
process, which was agreed to by provinces and territories, except in July 1958, by which time Newfoundland, Saskatchewan,
Quebec. The process meets federal and provincial or territorial Alberta, British Columbia and Manitoba were operating
interests of avoiding disputes related to the interpretation of the hospital insurance plans. By 1961, all provinces and territories
principles of the Act and, when this is not possible, resolving were participating in the program.
disputes in a fair, transparent and timely manner.
The second phase of the federal intervention supporting
The process includes the dispute avoidance activities of provincial and territorial health insurance programs resulted
government-to-government information exchange; discussions from the recommendations of the Royal Commission on Health
and clarification of issues as they arise; active participation Services (Hall Commission). In its final report, tabled in 1964,
of governments in ad hoc federal/provincial/territorial the Hall Commission recommended establishing a new program
committees on Act-related issues; and Canada Health Act that would ensure that all Canadians have access to necessary
advance assessments, upon request. medical care (physician services, outside a hospital setting).
Where dispute avoidance activities prove unsuccessful, The Medical Care Act was introduced in Parliament in
dispute resolution activities may be initiated, beginning with July 1966, and received Royal Assent on December 21, 1966.
government-to-government fact-finding and negotiations. If The implementation of the Medical Care program started
these are unsuccessful, either minister of health involved may on July 1, 1968. By 1972, all provinces and territories were
refer the issues to a third-party panel to undertake fact-finding participating in the program.
and provide advice and recommendations.
Originally, the federal government’s method of contributing
The federal Minister of Health has the final authority to to provincial and territorial hospital insurance programs was
interpret and enforce the Canada Health Act. In deciding based on the cost to provinces and territories of providing
whether to invoke the non-compliance provisions of the Act, insured hospital services. Under the HIDSA (1957), the
the Minister will take the panel’s report into consideration. federal government reimbursed the provinces and territories
for approximately 50 percent of the costs of hospital insurance.
A copy of Minister McLellan’s letter is included in Annex C In both cases, funding was conditional on certain program
of this report. criteria being met. Under the Medical Care Act (1966),

the federal contribution was set at 50 percent of the average Canada Health and Social Transfer
national per capita costs of the insured services, multiplied
by the number of insured persons in each province and territory. In the 1995 Budget, the federal government announced a
Funding protocols based on conditional grants continued until restructuring of the EPF Act, from then on to be called the
the move to block funding was made in fiscal year 1977–1978. Federal-Provincial Fiscal Arrangements Act, with provisions
for a Canada Health and Social Transfer (CHST).
Established Programs Financing The new omnibus or block transfer, beginning in fiscal year
1996–1997, merged the health and post-secondary education
On April 1, 1977, federal funding supporting insured health care funding of the EPF Act with Canada Assistance Plan funding
services was replaced by a block fund transfer with only general (the federal/provincial cost-sharing arrangement for social
requirements related to maintaining a minimum standard of services). When the CHST came into effect on April 1, 1996,
health services through the passage of the Federal-Provincial provinces and territories received CHST cash and tax transfer
Fiscal Arrangements and Established Programs Financing Act, in lieu of entitlements under the Canada Assistance Plan
1977. Known also as the EPF Act, the new legislation provided (CAP) and EPF. The new CHST cash amount provided to
federal contributions to the provinces and territories for insured provinces and territories was less than the combined values
hospital and medical care services (as well as for post-secondary of EPF and CAP, reflecting the need for fiscal restraint at
education) that were no longer tied to provincial expenditures. the time the CHST was introduced. The 1995 and 1996
Rather, federal contributions made in fiscal year 1975–1976 under Budget legislation provided for total CHST amounts (cash
the existing cost-sharing programs were designated as the base and tax transfers) for subsequent years, with an annual floor of
year for contributions, to be escalated by the rate of growth of $11 billion for the cash component to apply until 2002–2003.
nominal Gross National Product and increases to the population.
The new block fund was provided to uphold the national
Under the EPF Act, and subsequent funding arrangements, the criteria in the Canada Health Act (public administration,
total amount of the provincial and territorial health entitlement comprehensiveness, universality, portability and accessibility)
was made up of relatively equal cash and tax transfers. The and the provisions relating to extra-billing and user charges,
federal tax transfer involves the federal government ceding as well as maintaining the CAP-related national standard
some of its “tax room” to the provincial and territorial that no period of minimum residency be required or allowed
governments, reducing its tax rate to allow provinces to raise with respect to social assistance. Extended health care services
their tax rates by an equivalent amount. With the Established continued as part of the Act, subject only to the conditions of
Programs Financing “health” tax transfer, the changes in providing information and recognizing the federal transfer,
federal and provincial tax rates offset one another, meaning as set out in section 13 of the Act.
there was no net impact on taxpayers. The total amount of the
health care entitlement did not change. The new legislation also transferred the cash payment authority
from Health Canada to the Department of Finance. However,
The EPF Act also included a new transfer for the Extended the federal Minister of Health continued to be responsible for:
Health Care Services Program. This group of health care
services, defined as nursing home intermediate care, adult ■■ recommending the amounts of any deductions or with
residential care, ambulatory health care and the health aspects holdings pursuant to the conditions and criteria of the Act
of home care, were block funded on the basis of $20 per capita to the Governor in Council;
for fiscal year 1977–1978, and subject to the same escalator ■■ determining the amounts of any deductions pursuant to the
as insured health services. This portion of the EPF transfer extra-billing and user charges provisions of the Act; and
was made on a virtually unconditional basis and, unlike the
insured services transfer, was not subject to specified program ■■ ensuring that these amounts are communicated to the
delivery criteria. Department of Finance before the CHST payment dates.
Under the prevailing legislative framework, the Government From 1997 to 2000, there were several increases to the cash
of Canada was required to withhold all of the monthly health portion of the CHST, including increases to the cash floor.
care transfer to a province or territory for each month the In 1998, the cash floor was increased to $12.5 billion. With
program delivery criteria were not met. It was not until the the federal government’s return to surpluses, Budget 1999
enactment of the Canada Health Act in 1984 that special announced an additional $11.5 billion for health care. Of
deduction provisions came into force allowing for dollar- this amount, $8 billion was provided in CHST cash over the
for-dollar deductions for extra-billing and user charges, following four years. The remaining $3.5 billion was provided
and discretionary deductions when provincial and territorial through a trust fund notionally allocated over three years to
plans failed to fully comply with other provisions set out in provide provinces and territories flexibility over when to draw
the Act. These criteria and conditions remain in force to the down the funds. Budget 2000 then provided an additional
present day. $2.5 billion for health care through another trust fund to
provinces and territories, notionally allocated over four years.

2000 and 2003 Health Accords: Increasing and 2004 10-year Plan to Strengthen Health Care
Restructuring Federal Support for Health
Federal transfers to the provinces and territories were further
In 2000 and 2003, First Ministers met to discuss health care, increased as a result of the 10-Year Plan to Strengthen Health
focusing on reform, reporting and funding requirements. In Care. Signed by all first Ministers on September 16, 2004,
2000, the federal government announced $23.4 billion in this initiative committed the Government of Canada to
new spending over five years on health care renewal and early an additional $41.3 billion in funding, over ten years until
childhood development. This included an additional $21.1 billion 2013–2014, to the provinces and territories for health. This
dollars in increases to the CHST cash contributions, as well as an included $35.3 billion in increases to the CHT, $5.5 billion
additional $1.8 billion for targeted programs (medical equipment in Wait Times Reduction funding, and $500 million in
and primary health care reform), and $500 million for Canada support of diagnostic and medical equipment.
Health Infoway.
Budget 2007
In 2003, the government committed $36.8 billion over five
years to support priority areas of health reform (primary care, To restore fiscal balance in Canada, Budget 2007 put all major
home care and catastrophic drugs). This was provided through transfers on a long-term, principles-based track to 2013–2014.
$14 billion in increased CHST transfers and $16 billion for In order to provide comparable treatment for all Canadians,
the Health Reform Transfer, as well as $1.5 billion for medical regardless of where they live the budget legislated equal per
equipment. This was in addition to $5.3 billion in federal direct capita cash support for the CST, starting in 2007–2008, and the
spending on health information technologies, Aboriginal CHT, starting after the 10-Year Plan to Strengthen Health Care
health initiatives, patient safety and other health-related concludes in 2013–2014. In addition, Budget 2007 invested an
federal initiatives. additional $1 billion to help provinces and territories introduce
wait time guarantees, including initiatives delivered through
The federal government also agreed to restructure the CHST to Canada Health Infoway.
enhance the transparency and accountability of federal support
for health.
Recent Transfer Changes
As announced by the Government of Canada in December 2011,
The Canada Health Transfer and legislated in the Jobs, Growth and Long-term Prosperity Act,
The CHST was restructured into two new transfers, the Canada the CHT will continue to grow at an annual rate of 6 percent
Health Transfer (CHT) and Canada Social Transfer (CST), for an additional three years beyond 2013–2014 (i.e., until
effective April 1, 2004. The CHT supports the Government of 2016–2017). Starting in 2017–2018, the CHT will grow in line
Canada’s ongoing commitment to maintain the national criteria with a three-year moving average of nominal gross domestic
and conditions of the Canada Health Act. The CST; a block fund product growth, with funding guaranteed to increase by at least
that supports post-secondary education and social assistance three percent per year.
and social services, continues to give provinces and territories
Following up on the 2007 legislation for a transition to an equal
the flexibility to allocate funds among these social programs
per capita cash allocation for the CHT in 2014–2015, the Jobs,
according to their respective priorities.
Growth and Long-term Prosperity Act ensured a fiscally responsible
The existing CHST-legislated amounts were apportioned transition by providing protection so that no province or territory
between the new transfers, with the percentage of cash and will receive less than its 2013–2014 CHT cash allocation in
tax points allocated to each transfer reflecting provincial and subsequent years as a result of the move to equal per capita cash.
territorial spending patterns among the areas supported by the
Additional information on federal-provincial-territorial
transfers: 62 percent for the CHT and 38 percent for the CST.
funding arrangements is available upon request from
the Department of Finance, or by visiting its website at:
www.fin.gc.ca/access/fedprov-eng.asp#Major

CHAPTER 2
ADMINISTRATION
AND COMPLIANCE
ADMINISTRATION ■■ working with Health Canada Legal Services and Justice

Canada on litigation issues that implicate the CHA.
In administering the Canada Health Act (CHA), the federal
Minister of Health is assisted by Health Canada staff at
headquarters and in the regions, and by the Department Interprovincial Health Insurance
of Justice. Agreements Coordinating Committee
The Interprovincial Health Insurance Agreement Coordinating
The Canada Health Act Division Committee (IHIACC) was formed in 1991 to address issues
affecting the interprovincial billing of insured hospital and
The Canada Health Act Division of Health Canada is responsible physician services. The Committee includes members from
for administering the CHA. Members of the Division fulfill the each province and territory and a non-voting chair from
following ongoing functions: the Canada Health Act Division. The Canada Health Act
Division also provides secretariat functions for IHIACC.
■■ monitoring and analysing provincial and territorial health
insurance plans for compliance with the criteria, conditions, Through IHIACC, all provinces and territories participate in
and extra-billing and user charges provisions of the CHA; reciprocal hospital agreements, and all, with the exception of
■■ disseminating information on the CHA and on publicly Quebec, participate in reciprocal physician agreements. These
funded health care insurance programs in Canada; agreements generally ensure that a patient’s health card will be
accepted, in lieu of payment, when the patient receives insured
■■ responding to inquiries about the CHA and health insurance hospital or physician services in another province or territory.
issues received by telephone, mail and the Internet, from the The province or territory providing the service will then directly
public, members of Parliament, government departments, bill the patient’s home province. The intent of these agreements
stakeholder organizations and the media; is to ensure that Canadian residents do not have to pay directly
■■ developing and maintaining formal and informal partnerships for medically required hospital and physician services when
with health officials in provincial and territorial governments they travel within Canada.
for information sharing;
IHIACC’s Rate Review Working Group is responsible for
■■ producing the Canada Health Act Annual Report on the determining reciprocal billing rates to ensure that the host
administration and operation of the CHA; province or territory that is providing the health service is
■■ conducting issue analysis and policy research to provide compensated by the home province at a reasonable rate.
policy advice;
Issues related to registration and eligibility requirements are
■■ collaborating with provincial and territorial health department addressed through IHIACC’s Eligibility and Portability
representatives through the Interprovincial Health Insurance Working Group that is responsible for reviewing eligibility
Agreements Coordinating Committee (see below); issues and identifying potential inter-jurisdictional gaps in
■■ working in partnership with the provinces and territories health coverage.
to investigate and resolve compliance issues and pursue
activities that encourage compliance with the CHA; Of note, these agreements are interprovincial, not federal,
and while they facilitate the portability criterion they are not
■■ informing the federal Minister of Health of possible a requirement of the CHA.
non-compliance and recommending appropriate action
to resolve the issue; and

CHAPTER 2: ADMINISTRATION AND COMPLIANCE
COMPLIANCE Under the CHA, the definition of “hospital services” specifies

that standard or public ward level accommodation is an
Health Canada’s approach to resolving possible compliance insured service. Charges for preferred accommodation are
issues emphasizes transparency, consultation and dialogue permissible under the CHA only where such accommodation
with provincial and territorial health ministry officials. In is not medically required, and is provided at the patient’s
most instances, issues are successfully resolved through request. If ward level accommodation is not available or
consultation and discussion based on a thorough examination cannot be offered, patients must be provided private or semi-
of the facts. private accommodation at no charge. In January 2014, Health
Canada learned that two hospitals are being built in Quebec
The Canada Health Act Division monitors the operations of that will have only semi-private and private rooms, and that
provincial and territorial health care insurance plans in order to the Quebec health ministry considered permitting these
provide advice to the Minister on possible non-compliance with hospitals to charge fees for all stays. Health Canada reviewed
the Canada Health Act (CHA). Sources for this information the applicable provincial and territorial legislation and policies
include: provincial and territorial government officials and and found similar practices in Ontario and British Columbia.
publications; media reports; and correspondence received from In July 2014, Health Canada informed the health ministries of
the public and non-governmental organizations. British Columbia, Ontario and Quebec that such charges are
contrary to the CHA. British Columbia has since corrected
Staff in the Compliance and Interpretation Unit of the Canada the problem, while Ontario and Quebec are still examining
Health Act Division assess issues of concern and complaints on the issue.
a case-by-case basis. The assessment process involves compiling
all facts and information related to the issue and taking As detailed in the 2013–2014 Canada Health Act Annual
appropriate action. Verifying the facts with provincial and Report, in January 2011, the Vancouver General Hospital in
territorial health officials may reveal issues that are not directly British Columbia began charging patients a fee when they
related to the CHA, while others may pertain to the CHA but elect to have robot-assisted surgery versus the conventional
are a result of misunderstanding or miscommunication, such surgical alternative for certain medically necessary procedures
as eligibility for health insurance coverage and portability of (e.g., prostatectomy, hysterectomy). In October 2013, Health
health services within and outside Canada, and are resolved Canada informed the British Columbia health ministry that
quickly with provincial or territorial assistance. since the robot is a piece of surgical equipment used to perform
an insured hospital service, it falls within the definition of
In instances where a CHA issue has been identified and insured hospital services under the CHA. For that reason,
remains after initial enquiries, Division officials ask the there should be no patient charges. In December 2014, the
jurisdiction in question to investigate the matter and report BC Health Ministry wrote to Health Canada to confirm
back. Division staff discuss the issue and its possible resolution that it had directed the hospital to cease charging patients
with provincial or territorial officials. Only if the issue is not for robot-assisted surgeries by January 31, 2015.
resolved to the satisfaction of the Division after following
the aforementioned steps, is it brought to the attention of the During 2014–2015, Health Canada continued to consult with
federal Minister of Health. Alberta Health about private primary health care clinics that
charge patients annual enrollment and membership fees. If
the receipt of insured services is conditional upon the payment
COMPLIANCE ISSUES of fees, it would pose concerns under the accessibility criterion
of the CHA. Typically, the fees cover a basket of uninsured
For the most part, provincial and territorial health care services but also promise quick access to and unrushed
insurance plans meet the criteria and conditions of the appointments with family physicians. In November 2013,
Canada Health Act (CHA). However, on the basis of their Alberta Health informed Health Canada that it had
health ministry’s report to Health Canada, a deduction in the completed an audit of an Edmonton clinic, which resulted in
amount of $241,637 was taken from the March 2015 Canada the clinic better communicating with patients about charges
Health Transfer payments to British Columbia in respect of for uninsured services. Alberta Health conducted similar
extra-billing and user charges for insured health services at audits at two other clinics and shared the results of all three
private clinics in fiscal year 2012–2013. audits with Health Canada in January 2015. In March 2015,
Health Canada requested confirmation that processes were in
Health Canada continues to monitor provincial and territorial place to reimburse patients who had been charged for insured
compliance with the CHA. The following key developments services and that such charges had ceased. As well, the Alberta
occurred since the 2013–2014 Canada Health Act Annual College of Physicians and Surgeons continues to consider new
Report was published: or amended practice standards to guide physicians involved in
these arrangements.

In November 2014, Health Canada provided an advance because certification of medical necessity by two physicians,
assessment under the CHA to Nova Scotia on a proposal by and performance of the service by a specialist in gynecology or
some ophthalmologists to charge patients for certain tests when obstetrics in a hospital are no longer required. Prince Edward
they are performed in the physician’s office instead of a hospital, Island service has improved because the province has eliminated
in respect of the cost of the technology used. Health Canada the need for a referral from an Island doctor and now allows
confirmed that no additional fees can be charged in conjunction women to self-refer to a Moncton, New Brunswick, hospital.
with a medically necessary physician service. However, accessibility and comprehensiveness concerns remain
because neither province covers private clinic abortions under
Also in November 2014, Prince Edward Island asked Health their respective provincial health insurance plans.
Canada if there would be CHA implications if a proposed
non-profit clinic were funded by a charitable foundation, Health Canada remains concerned about patient payments for
where health services would be provided without a charge drugs administered in hospital out-patient clinics and their
to patients by a nurse practitioner. Health Canada informed appropriateness under the CHA, since drugs and biological
Prince Edward Island that since the services were neither products administered in hospitals that are medically necessary
provided by physicians nor in a hospital, they are not under for the purpose of maintaining health, preventing disease or
the ambit of the CHA. Had patients been charged directly for diagnosing or treating an injury, illness or disability are insured
these services, Health Canada would have concerns about the health services under the CHA.
migration of physician services to settings in which insured
residents must pay to receive them. MRI and CT services are also considered to be insured health
services when they are medically necessary for the purpose
In March 2014, Health Canada asked the Ministry of Health of maintaining health, preventing disease or diagnosing or
and Long-term Care in Ontario for its assessment of illegal treating an injury, illness or disability, and are provided in
patient charges alleged by the Ontario Health Coalition in its a hospital or a facility providing hospital care, but patient
report, “For Health or Wealth.” Health Canada also inquired charges for these services are levied by private clinics in
if the My Health Report web-based service allows subscribers British Columbia, Alberta, Quebec, New Brunswick and
to obtain expedited access to insured physician services. On Nova Scotia.
August 8, 2014, the Ontario health ministry replied, saying
that no evidence of illegal charges alleged by the Ontario Physician services received by Quebec residents when out-of-
Health Coalition was found. The Ontario health ministry also province are not reimbursed at host province rates, which is a
noted that it has published information bulletins to physicians, requirement of the portability criterion of the CHA. Canadians
hospitals and licensed independent health facilities, to remind from provinces other than Quebec also report difficulties having
them of the prohibitions on extra-billing and user charges, as their provincial or territorial health insurance cards honoured
well as queue-jumping, under the Ontario Commitment to the while out-of-province, particularly by walk-in clinics, which
Future of Medicare Act and the Independent Health Facilities Act. runs counter to the spirit of the CHA. For all jurisdictions,
With regards to the My Health Report web-based service, except Prince Edward Island and the three territories, the per
Ontario noted that the description of services on the diem rates for out-of-country hospital services appear lower than
web-site no longer includes a reference to expedited care. home province or territory rates, which is also a requirement of
In both of these cases, Health Canada considers these issues the portability criterion of the CHA.
to be resolved.
In March 2015, Health Canada wrote to the Quebec Ministry HISTORY OF DEDUCTIONS

of Health concerning patient charges by physicians, when they
provide certain publicly insured health services in their offices AND REFUNDS UNDER THE
or private clinics. Health Canada’s consultation with Quebec
on this issue is ongoing.
CANADA HEALTH ACT
The Canada Health Act (CHA), which came into force
During 2014–2015, Health Canada continued to monitor the April 1, 1984, reaffirmed the national commitment to the
following ongoing compliance and interpretation issues: original principles of the Canadian health care system, as
embodied in the previous legislation, the Medical Care Act
Abortion services are insured in all provinces and territories;
and the Hospital Insurance and Diagnostic Services Act.
however, access to these insured services varies within and
By putting into place mandatory dollar-for-dollar penalties
between jurisdictions across the country. In Prince Edward
for extra-billing and user charges, the federal government
Island and New Brunswick, the services are only covered if
took steps to eliminate the proliferation of direct charges
performed in a hospital (for example, private clinic procedures
for hospital and physician services, judged to be restricting
are not covered). In addition, Prince Edward Island lacks
the access of many Canadians to health care services due
abortion services on the island and residents must travel off the
to financial considerations.
island to access them. In New Brunswick, access has improved

During the period 1984 to 1987, subsection 20(5) of From November 1995 to June 1996, total deductions of
the CHA provided for deductions in respect of these $3,585,000 were made to Alberta’s cash contribution in
charges to be refunded to the province if the charges were respect of facility fees charged at clinics providing surgical,
eliminated before April 1, 1987. By March 31, 1987, it ophthalmological and abortion services. On October 1, 1996,
was determined that all provinces, which had extra-billing Alberta prohibited private surgical clinics from charging
and user charges, had taken appropriate steps to eliminate patients a facility fee for medically necessary services for
them. Accordingly, by June 1987, a total of $244,732,000 in which the physician fee was billed to the provincial health
deductions was refunded to New Brunswick ($6,886,000), insurance plan.
Quebec ($14,032,000), Ontario ($106,656,000), Manitoba
($1,270,000), Saskatchewan ($2,107,000), Alberta Similarly, due to facility fees allowed at an abortion clinic,
($29,032,000) and British Columbia ($84,749,000). a total of $280,430 was deducted from Newfoundland and
Labrador’s cash contribution before these fees were eliminated,
Following the CHA’s initial three-year transition period, effective January 1, 1998.
under which refunds to provinces and territories for deductions
were possible, penalties under the CHA did not reoccur until From November 1995 to December 1998, deductions from
fiscal year 1994–1995. Please refer to the table at the end of Manitoba’s cash contribution amounted to $2,055,000, ending
this section for a summary of deductions and refunds that with the confirmed elimination of user charges at surgical and
have been made to provincial or territorial transfer payments ophthalmology clinics, effective January 1, 1999. However,
since 1994–1995. during fiscal year 2001–2002, a monthly deduction (from
October 2001 to March 2002 inclusive) in the amount of
In the early 1990s, as a result of a dispute between $50,033 was levied against Manitoba’s Canada Health and
the British Columbia Medical Association and the Social Transfer (CHST) cash contribution on the basis of a
British Columbia government over compensation, several financial statement provided by the province showing that
doctors opted out of the provincial health insurance plan and actual amounts charged with respect to user charges for
began billing their patients directly. Some of these doctors insured services in fiscal years 1997–1998 and 1998–1999 were
billed their patients at a rate greater than the amount the greater than the deductions levied on the basis of estimates.
patients could recover from the provincial health insurance This brought total deductions levied against Manitoba
plan. This higher amount constituted extra-billing under the to $2,355,201.
CHA. Deductions began in May 1994, relating to fiscal year
1992–1993, and continued until extra-billing by physicians With the closure of a private clinic in Halifax effective
was banned when changes to British Columbia’s Medicare November 27, 2003, Nova Scotia was deemed to be in
Protection Act came into effect in September 1995. In total, compliance with the Federal Policy on Private Clinics. Before it
$2,025,000 was deducted from British Columbia’s cash closed, total deductions of $372,135 were made to Nova Scotia’s
contribution for extra-billing that occurred in the province CHST cash contribution for its failure to cover facility charges
between 1992–1993 and 1995–1996. These deductions were to patients while paying the physician fee. A final deduction
non-refundable, as were all subsequent deductions. of $5,463 was taken from the March 2005 Canada Health
Transfer (CHT) payment to Nova Scotia as a reconciliation
In January 1995, federal Minister of Health, Diane Marleau, of deductions that had already been taken for 2002–2003.
expressed concerns to her provincial and territorial colleagues A one-time positive adjustment in the amount of $8,121 was
about the development of two-tiered health care and the made to Nova Scotia’s March 2006 CHT payment to reconcile
emergence of private clinics charging facility fees for medically amounts actually charged in respect of extra-billing and user
necessary services. As part of her communication with the charges with the penalties that had already been levied based
provinces and territories, Minister Marleau announced that on provincial estimates reported for fiscal 2003–2004.
the provinces and territories would be given more than nine
months to eliminate these user charges, but that any province In January 2003, British Columbia provided a financial statement
that did not, would face financial penalties under the CHA. in accordance with the Canada Health Act Extra-billing and
Accordingly, beginning in November 1995, deductions were User Charges Information Regulations, indicating aggregate
applied to the cash contributions to Alberta, Manitoba, Nova amounts actually charged with respect to extra-billing and
Scotia, and Newfoundland and Labrador for non-compliance user charges during fiscal year 2000–2001, totalling $4,610.
with the Federal Policy on Private Clinics. Accordingly, a deduction of $4,610 was made to the March 2003
CHST cash contribution.

In 2004, British Columbia did not report to Health Canada A deduction of $1,100 was taken from the March 2005 CHT
the amounts of extra-billing and user charges actually payment to Newfoundland and Labrador as a result of patient
charged during fiscal year 2001–2002, in accordance with charges for a magnetic resonance imaging scan in a hospital
the requirements of the Extra-billing and User Charges which occurred during 2002–2003. The March 2007 CHT
Information Regulations. As a result of reports that payment to Nova Scotia was reduced by $9,460 in respect of
British Columbia was investigating cases of user charges, extra-billing during fiscal year 2004–2005.
a $126,775 deduction was taken from British Columbia’s
March 2004 CHST payment, based on the amount Since March 2011, deductions totalling $102,249 have been
the Minister estimated to have been charged during taken from CHT payments to Newfoundland and Labrador for
fiscal year 2001–2002. extra-billing and user charges, based on charges reported by the
province to Health Canada. Since these charges resulted from
Since 2005, $1,253,145 in cash transfer deductions have been services provided by an opted-out dental surgeon who has since
taken from British Columbia’s CHT payments in light of left the province, Health Canada considers this matter resolved.
patient charges reported by the province to Health Canada.
The deduction taken in 2012–2013 in respect of fiscal year Since the passage of the CHA, from April 1984 to March 2013,
2010–2011 was estimated by the federal Minister of Health deductions totaling $10,112,447 have been taken from transfer
and represents the aggregate of the amounts reported to Health payments in respect of the extra-billing and user charges
Canada by British Columbia and those reported publicly provisions of the CHA. This amount excludes deductions
as the result of an audit performed by the Medical Services totaling $244,732,000 that were made between 1984 and 1987
Commission of British Columbia. Deductions for each year and subsequently refunded to the provinces when extra-billing
are detailed in a table following this passage. and user charges were eliminated.

DEDUCTIONS AND REFUNDS TO CHST/CHT CASH CONTRIBUTIONS IN ACCORDANCE

WITH THE CANADA HEALTH ACT SINCE 1994 –1995 (IN DOLL ARS)
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.
• 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.

DEDUCTIONS AND REFUNDS TO CHST/CHT CASH CONTRIBUTIONS IN ACCORDANCE

WITH THE CANADA HEALTH ACT SINCE 1994 –1995 (IN DOLL ARS) (CONTINUED)
2005–2006 2006–2007 2007–2008 2008–2009 2009–2010 2010–2011 2011–2012 2012–2013 2013–2014 2014–2015 Total
0 0 0 0 0 3,577 58,679 50,758 (10,765) 0 383,779
0 0 0 0 0 0 0 0 0 0 0
(8,121) 9,460 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 2,355,201
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 3,409,530
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 10,112,447

CHAPTER 3
PROVINCIAL AND TERRITORIAL

HEALTH CARE INSURANCE
PLANS IN 2014–2015
The following chapter presents the 13 provincial and territorial The process for the Canada Health Act Annual Report
health insurance plans that make up the Canadian publicly 2014–2015 was launched late spring 2015 with bilateral
funded health insurance system. The purpose of this chapter teleconferences with each jurisdiction. An updated User’s
is to demonstrate clearly and consistently the extent to which Guide was also sent to the provinces and territories at that time.
provincial and territorial plans fulfilled the requirements
of the Canada Health Act program criteria and conditions
in 2014–2015. INSURANCE PLAN DESCRIPTIONS
Officials in the provincial, territorial and federal governments For the following chapter, provincial and territorial officials
have collaborated to produce the detailed plan overviews were asked to provide a narrative description of their health
contained in Chapter 3. The information that Health Canada insurance plan. The descriptions follow the program criteria
requested from the provincial and territorial departments of areas of the Canada Health Act in order to illustrate how the
health for the report consists of two components: plans satisfy these criteria. This narrative format also allows
each jurisdiction to indicate how it met the Canada Health Act
■■ a narrative description of the provincial or territorial health requirement for the recognition of federal contributions that
care system relating to the criteria and conditions of the Act, support insured and extended health care services.
which can be found following this introduction; and
■■ statistical information related to insured health services.
The narrative component is used to help with the monitoring

PROVINCIAL AND TERRITORIAL
and compliance of provincial and territorial health care plans HEALTH CARE INSURANCE
with respect to the requirements of the Act, while statistics help
to identify current and future trends in the Canadian health
PLAN STATISTICS
care system. While all provinces and territories have submitted Over time, the section of the annual report containing the
detailed descriptive information on their health insurance plans, statistical information submitted from the provinces and
Quebec chose not to submit supplemental statistical information territories has been simplified and streamlined based on
which is contained in the tables in this year’s report. feedback received from provincial and territorial officials,
and based on reviews of data quality and availability. The
To help provinces and territories prepare their submissions
supplemental statistical information tables can be found at the
to the annual report, Health Canada provided them with the
end of each provincial or territorial narrative, except for Quebec.
document; Canada Health Act Annual Report 2014–2015:
A Guide for Updating Submissions (User’s Guide). The User’s The purpose of the statistical tables is to place the administra-
Guide is designed to help provinces and territories meet Health tion and operation of the Canada Health Act in context and to
Canada’s reporting requirements. Annual revisions to the provide a national perspective on trends in the delivery and
guide are based on Health Canada’s analysis of health plan funding of insured health services in Canada that are within
descriptions from previous annual reports and its assessment the scope of the Act.
of emerging issues relating to insured health services.

CHAPTER 3: PROVINCIAL AND TERRITORIAL HEALTH CARE INSURANCE PLANS IN 2014–2015
The statistical tables contain resource and cost data for Insured Hospital Services Provided to Residents in Another
insured hospital, physician and surgical-dental services by Province or Territory: This sub-section presents out-of-
province and territory for five consecutive years ending on province or out-of-territory insured hospital services that are
March 31, 2015. All information was provided by provincial paid for by a person’s home jurisdiction when they travel to
and territorial officials. other parts of Canada.
Although efforts are made to capture data on a consistent basis, Insured Hospital Services Provided Outside Canada:
differences exist in the reporting on health care programs This represents residents’ hospital costs incurred while
and services between provincial and territorial governments. travelling outside of Canada that are paid for by their home
Therefore, comparisons between jurisdictions are not made. province or territory.
Provincial and territorial governments are responsible for
the quality and completeness of the data they provide. Insured Physician Services Within Own Province or
Territory: Statistics in this sub-section relate to the provision
of insured physician services to residents in each province or
Organization of the Information territory, as well as to visitors from other regions of Canada.
Information in the statistical tables is grouped according Insured Physician Services Provided to Residents in Another
to the nine subcategories described below. Province or Territory: This sub-section reports on physician
services that are paid by a jurisdiction to other provinces or
Registered Persons: Registered persons are the number territories for their visiting residents.
of residents registered with the health care insurance plans
of each province or territory. Insured Physician Services Provided Outside Canada:
This represents residents’ medical costs incurred while
Insured Hospital Services Within Own Province or travelling outside of Canada that are paid by their home
Territory: Statistics in this sub-section relate to the provision province or territory.
of insured hospital services to residents in each province or
territory, as well as to visitors from other regions of Canada. Insured Surgical-Dental Services Within Own Province or
Territory: The information in this subsection describes insured
surgical-dental services provided in each province or territory.

NEWFOUNDLAND AND LABRADOR
INTRODUCTION capacity, to provide vital programming in long term care and

community support services through the province, investments
The Department of Health and Community Services (the in infrastructure and redevelopment of facilities.
Department) is responsible for setting the overall strategic
In Newfoundland and Labrador, health services are provided
directions and priorities for the health and community services
to over 500,000 residents by approximately 20,000 health care
system throughout Newfoundland and Labrador. In 2014, the
providers, support staff and administrators.
Department of Seniors, Wellness and Social Development was
created. As a result, the responsibility for the Healthy Living
Division and the Office of Aging and Seniors has moved to the
new department. This resulted in a slight change in the lines 1.0 PUBLIC ADMINISTRATION
of business for the Department of Health and Community
Services with the removal of the following divisions:
1) Health Promotion and Wellness; 2) Healthy Aging 1.1 Health Care Insurance Plan and
and Seniors; and 3) Support to Community Agencies. Public Authority
The Department works with stakeholders to develop and Health care insurance plans managed by the Department
enhance policies, legislation, provincial standards and strategies of Health and Community Services include the Hospital
to support individuals, families and communities to achieve Insurance Plan and the Medical Care Plan (MCP). Both plans
optimal health and well-being. The Department provides a lead are non-profit and publicly administered.
role in policy, planning, program development, and support
to the four regional health authorities. The Department also The Hospital Insurance Agreement Act is the legislation that
works with stakeholders to ensure high quality, cost effective enables the Hospital Insurance Plan. The Act gives the
and timely health services are available for all Newfoundlanders Minister of Health and Community Services the authority
and Labradorians. to make regulations for providing insured services on
uniform terms and conditions to residents of the province
The Department provides leadership, coordination, monitoring under the conditions specified in the Canada Health Act and
and support to the regional health authorities who deliver the its regulations.
majority of publicly funded health services in the province, as
well as other entities who deliver programs and services. This The Medical Care Insurance Act, 1999 requires the Minister to
ensures quality, efficiency and effectiveness in areas such as administer a plan of medical care insurance for residents of
the administration of health care facilities; access and clinical the province. It provides for the development of regulations to
efficiency; programs for seniors, persons with disabilities ensure that the provisions of the statute meet the requirements
and persons with mental health and addictions issues as well of the Canada Health Act as it relates to administering the MCP.
as long-term care and community support services; health
professional education and training programs; the control, The MCP facilitates the delivery of comprehensive medical
possession, handling, keeping and sale of food and drugs; care to all residents of the province by implementing policies,
the preservation and promotion of health; the prevention and procedures and systems that permit appropriate compensation
control of disease; and public health and the enforcement of to providers for rendering insured professional services.
public health standards. The MCP operates in accordance with the provisions of the
Medical Care Insurance Act, 1999 and regulations, and in
Budget 2014–2015 included an investment of nearly $3 billion compliance with the Canada Health Act.
to help ensure better health, better care and better value for
Newfoundlanders and Labradorians. Investments were made There were no substantive legislative amendments to the
to increase access to diagnostic and treatment services for Medical Care Insurance Act, 1999 or the Hospital Insurance
children with autism and other conditions, increased dialysis Agreement Act in 2014–2015.

CHAPTER 3: NEWFOUNDLAND AND LABRADOR
1.2 Reporting Relationship Insured hospital services are provided for in-patients and
out-patients in 15 hospitals, 22 community health centres
The Department is mandated with administering the Hospital and 14 community clinics as well as numerous health and
Insurance and Medical Care Plans. The Department reports community services clinics throughout the province. Insured
on these plans through the regular legislative processes, services include: accommodations and meals at the standard
e.g., Public Accounts and the Social Services Committees ward level; nursing services; laboratory, radiology and
of the House of Assembly. other diagnostic procedures; drugs, biological and related
preparations; medical and surgical supplies; operating room,
The Government of Newfoundland and Labrador has case room and anaesthetic facilities; rehabilitative services
a provincial planning and reporting requirement for all (e.g., physiotherapy, occupational therapy, speech language
government departments, including the Department of pathology and audiology); out-patient and emergency visits;
Health and Community Services. Under the Transparency and and day surgery.
Accountability Act, the Department of Health and Community
Services and the 12 entities that report to the Minister, including The coverage policy for insured hospital services is linked
regional health authorities (RHAs), produce a strategic plan once to the coverage policy for insured medical services. The
every three years and report annually on performance. Plans and Department of Health and Community Services manages the
reports are tabled in the House of Assembly and posted on the process of adding or de-listing a hospital service from the list
Department’s website. http://www.assembly.nl.ca of insured services based on direction from the Lieutenant-
Governor in Council. There were no services added or de-listed
The 2014–2015 Department of Health and Community Services in 2014–2015.
Annual Report will be tabled in the House of Assembly by the
end of September 30, 2015.
2.2 Insured Physician Services
1.3 Audit of Accounts The enabling legislation for insured physician services is the
Medical Care Insurance Act, 1999 and the regulations made
Each year, the province’s Auditor General independently thereunder, which include the:
examines provincial public accounts. MCP expenditures are
considered a part of the public accounts. While respecting ■■ Medical Care Insurance Insured Services Regulations;
privacy and personal information, the Auditor General has full ■■ Medical Care Insurance Beneficiaries and Inquiries
and unrestricted access to code based MCP records. Regulations; and
The four RHAs are subject to financial statement audits, ■■ Physicians and Fee Regulations.
reviews, and compliance audits. Financial statement audits
are performed by independent auditing firms that are selected In 2014–2015 there were 1,210 physicians registered in
by the health authorities. Review engagements, compliance the province.
audits and physician audits were carried out by personnel
For purposes of the Act, the following services are covered:
from the Department under the authority of the Medical Care
Insurance Act, 1999. Physician records and professional medical ■■ all services properly and adequately provided by physicians
corporation records were reviewed to ensure that the records to beneficiaries suffering from an illness requiring medical
supported the services billed and that the services are insured treatment or advice;
under the MCP.
■■ group immunizations or inoculations carried out by
Beneficiary audits were performed by personnel from the physicians at the request of the appropriate authority; and
Department under the Medical Care Insurance Act, 1999. ■■ diagnostic and therapeutic x-ray and laboratory services in
Individual providers are randomly selected on a bi-weekly facilities approved by the appropriate authority that are not
basis for audit. provided under the Hospital Insurance Agreement Act and
regulations made under the Act.
2.0 COMPREHENSIVENESS Physicians can choose not to participate in the health care
insurance plan as outlined in section 12(1) of the Medical Care
Insurance Act, 1999, namely:
2.1 Insured Hospital Services
12 (1) Where a physician providing insured services is not
The Hospital Insurance Agreement Act and the Hospital Insurance a participating physician, and the physician provides an
Regulations, made thereunder, provide for insured hospital insured service to a beneficiary, the physician is not subject
services in Newfoundland and Labrador. to this Act or the regulations relating to the provision of

insured services to beneficiaries or the payment to be made 2.4 Uninsured Hospital, Physician and
for the services except that he or she shall:
Surgical-Dental Services
a) before providing the insured service, if he or she wishes
to reserve the right to charge the beneficiary for the Hospital services not covered by MCP include: preferred
service an amount in excess of that payable by the accommodation at the patient’s request; cosmetic surgery
Minister under this Act, inform the beneficiary that and other services deemed to be medically unnecessary;
he or she is not a participating physician and that the ambulance or other patient transportation before admission
physician may so charge the beneficiary; and or upon discharge; private duty nursing arranged by the
patient; non-medically required x-rays or other services for
b) provide the beneficiary to whom the physician has employment or insurance purposes; drugs (except anti-rejection
provided the insured service with the information and AZT drugs) and appliances issued for use after discharge
required by the Minister to enable payment to be made from hospital; bedside telephones, radios or television sets
under this Act to the beneficiary in respect of the for personal, non-teaching use; fibreglass splints; services
insured service. covered by the Workplace Health, Safety and Compensation
Commission or by other federal or provincial legislation; and
(2) Where a physician who is not a participating physician
services relating to therapeutic abortions performed in non-
provides insured services through a professional medical
accredited facilities or facilities not approved by the College
corporation, the professional medical corporation is not,
of Physicians and Surgeons of Newfoundland and Labrador.
in relation to those services, subject to this Act or the
regulations relating to the provision of insured services The use of the hospital setting for any services deemed
to beneficiaries or the payment to be made for the not insured by the MCP are also uninsured under the
services and the professional medical corporation and the Hospital Insurance Plan. For purposes of the Medical Care
physician providing the insured services shall comply with Insurance Act, 1999, the following is a list of non-insured
subsection (1). physician services:
As of March 31, 2015 there were no physicians who had opted ■■ any advice given by a physician to a beneficiary by telephone;
out of the Medical Care Plan (MCP).
■■ the dispensing by a physician of medicines, drugs or medical
Lieutenant-Governor in Council approval is required to add appliances and the giving or writing of medical prescriptions;
to or to de-insure a physician service from the list of insured ■■ the preparation by a physician of records, reports or
services. This process is managed by the Department in certificates for, or on behalf of, or any communication to,
consultation with various stakeholders. or relating to, a beneficiary;
■■ any services rendered by a physician to the spouse and
2.3 Insured Surgical-Dental Services children of the physician;
■■ any service to which a beneficiary is entitled under an Act
The provincial Surgical-Dental Program is a component of the of the Parliament of Canada, an Act of the Province of
MCP. Surgical-dental treatments provided to a beneficiary and Newfoundland and Labrador, an Act of the legislature of
carried out in a hospital by a licensed oral surgeon or dentist are any province of Canada, or any law of a country or part of
covered by MCP if the treatment is specified in the Surgical- a country;
Dental Services Schedule.
■■ the time taken or expenses incurred in travelling to consult
Dentists may opt out of the MCP. These dentists must advise a beneficiary;
the patient of their opted-out status, state the fees expected, ■■ ambulance service and other forms of patient transportation;
and provide the patient with a written record of services and
fees charged. As of March 31, 2015, there were no opted-out ■■ acupuncture and all procedures and services related to
dentists. There was no extra-billing in 2014–2015. acupuncture, excluding an initial assessment specifically
related to diagnosing the illness proposed to be treated
Because the Surgical-Dental Program is a component of the by acupuncture;
MCP, management of the program is linked to the MCP ■■ examinations not necessitated by illness or at the request
process regarding changes to the list of insured services. of a third party except as specified by the Department;
Addition of a surgical-dental service to the list of insured ■■ plastic or other surgery for purely cosmetic purposes,
services must be approved by the Minister. unless medically indicated;

■■ laser treatment of telangiectasia;

3.0 UNIVERSALITY
■■ testimony in a court;
■■ visits to optometrists, general practitioners and ophthal 3.1 Eligibility
mologists solely for determining whether new or
replacement glasses or contact lenses are required; There were 533,156 people registered with the Medical Care
■■ the fees of a dentist, oral surgeon or general practitioner Plan as of March 31, 2015. Residents of Newfoundland and
for routine dental extractions performed in hospital; Labrador are eligible for coverage under the Medical Care
Insurance Act, 1999 and the Hospital Insurance Agreement Act. The
■■ fluoride dental treatment for children under four years of age; Medical Care Insurance Act, 1999 defines a “resident” as a person
■■ excision of xanthelasma; lawfully entitled to be or to remain in Canada, who makes his or
her home and is ordinarily present in the province, but does not
■■ circumcision of newborns;
include tourists, transients or visitors to the province.
■■ hypnotherapy;
The Medical Care Insurance Beneficiaries and Inquiries
■■ medical examination for drivers;
Regulations identify those residents eligible to receive coverage
■■ alcohol/drug treatment outside Canada; under the plans. The Medical Care Plan (MCP) has established
■■ consultation required by hospital regulation; rules to ensure that the regulations are applied consistently and
fairly in processing applications for coverage. MCP applies the
■■ therapeutic abortions performed in the province at a facility standard that persons moving to Newfoundland and Labrador
not approved by the College of Physicians and Surgeons of from another province become eligible on the first day of the
Newfoundland and Labrador; third month following the month of their arrival.
■■ sex reassignment surgery, when not recommended by the
Clarke Institute of Psychiatry; Persons not eligible for coverage under the plans include:
students and their dependants already covered by another
■■ in vitro fertilization and OSST (ovarian stimulation and province or territory; dependents of residents if covered by
sperm transfer); another province or territory; certified refugees and refugee
■■ reversal of previous sterilization procedure; claimants and their dependents; foreign workers with
employment authorizations and their dependants who do
■■ surgical, diagnostic or therapeutic procedures provided in
not meet the established criteria; tourists, transients, visitors
facilities as of January 1998 other than those covered under
and their dependents; Canadian Forces personnel; inmates
the Hospital Insurance Agreement Act or approved by the
of federal prisons; and armed forces personnel from other
appropriate authority under paragraph 3(d) of the Medical
countries who are stationed in the province. If the status
Care Insurance Insured Services Regulations; and
of these individuals changes, they must meet the criteria
■■ other services not within the ambit of section 3 of the for eligibility as noted above in order to become eligible.
Medical Care Insurance Insured Services Regulations.
The majority of diagnostic services (e.g., laboratory services and 3.2 Other Categories of Individuals
x-ray) are performed within public facilities in the province.
Hospital policy concerning access ensures that third parties Foreign workers, international students, clergy and dependants
are not given priority access. of North Atlantic Treaty Organization (NATO) personnel
are eligible for benefits. Holders of Minister’s permits are also
Medical goods and services that are implanted and associated eligible, subject to MCP approval.
with an insured service are provided free of charge to the
patient and are consistent with national standards of practice.
Patients retain the right to financially upgrade standard medical
goods or services. Standards for medical goods are developed
4.0 PORTABILITY
by the hospitals providing those services in consultation with
service providers.
4.1 Minimum Waiting Period
The Medical Care Insurance Act, 1999 provides the Lieutenant-
Insured persons moving to Newfoundland and Labrador from
Governor in Council with the authority to make regulations
other provinces or territories are entitled to coverage on the first
prescribing which services are or are not insured services for
day of the third month following the month of arrival.
the purpose of the Act.
Persons arriving from outside Canada to establish residence are
entitled to coverage on the day of arrival. The same applies to
discharged members of the Canadian Forces, and individuals

released from federal penitentiaries. For coverage to be effective; ■■ Persons leaving the province for employment purposes
however, registration is required under the Medical Care Plan may receive a certificate for coverage up to 12 months.
(MCP). Immediate coverage is provided to persons from outside Verification of employment may be required.
Canada authorized to work in the province for one year or more. ■■ Persons must not establish residence in another province,
territory or country while maintaining coverage under the
Newfoundland MCP.
4.2 Coverage During Temporary Absences
■■ For out-of-province trips of 30 days or less, an out-of-
in Canada province coverage certificate is not required, but will be
Newfoundland and Labrador is a party to the Interprovincial issued upon request.
Agreement on Eligibility and Portability regarding matters ■■ For out-of-province trips lasting more than 30 days, a
pertaining to portability of insured services in Canada. certificate is required as proof of a resident’s ability to pay
for services while outside the province.
Sections 12 and 13 of the Hospital Insurance Regulations
define portability of hospital coverage during absences both Failure to request out-of-province coverage or failure to abide
within and outside Canada. The eligibility policy for insured by the residency rules may result in the resident having to pay
hospital services is linked to the eligibility policy for insured for medical or hospital costs incurred outside the province.
physician services.
Insured residents moving permanently to other parts of Canada
Coverage is provided to residents during temporary absences are covered up to and including the last day of the second
within Canada. The Government of Newfoundland and month following the month of departure.
Labrador has entered into formal agreements (e.g., the Hospital
Reciprocal Billing Agreement) with other provinces and
territories for the reciprocal billing of insured hospital services. 4.3 Coverage During Temporary Absences
In-patient costs are paid at standard rates approved by the Outside Canada
host province or territory. In-patient, high-cost procedures
and out-patient services are payable based on national The province provides coverage to residents during temporary
rates agreed to by provincial and territorial health plans absences outside Canada. Out-of-country insured hospital
through the Interprovincial Health Insurance Agreements in-patient and out-patient services are covered for emergencies,
Coordinating Committee. sudden illness, and elective procedures at established rates.
Hospital services are considered under the Plan when the
Medical services incurred in all provinces (except Quebec) or insured services are provided by a recognized facility (licensed
territories, are paid through the Medical Reciprocal Billing or approved by the appropriate authority within the state or
Agreement at host province or territory rates. Claims for country in which the facility is located) outside Canada. The
medical services received in Quebec are submitted by the maximum amount payable by the government’s hospitalization
patient to the MCP for payment at host province rates. plan for out-of-country in-patient hospital care is $350 per day,
In order to qualify for out-of-province coverage, a beneficiary if the insured services are provided by a community or regional
must comply with the legislation and MCP rules regarding hospital. Where insured services are provided by a tertiary
residency in Newfoundland and Labrador. A resident must care hospital (a highly specialized facility), the approved rate
reside in the province at least four consecutive months in each is $465 per day. The approved rate for out-patient services
12-month period to qualify as a beneficiary. Generally, the rules is $62 per visit and hemodialysis is $330 per treatment.
regarding medical and hospital care coverage during absences The approved rates are paid in Canadian funds.
include the following: Physician services are covered for emergencies or sudden illness,
■■ Before leaving the province for extended periods, a resident and are also insured for elective services not available in the
must contact the MCP to obtain an out-of-province province or within Canada. Emergency Physician services are
coverage certificate. paid at the same rate as would be paid in Newfoundland and
Labrador for the same service. If the elective services are not
■■ Beneficiaries leaving for vacation purposes may receive available in Newfoundland and Labrador, they are usually paid
an initial out-of-province coverage certificate of up to at Ontario rates, or at rates that apply in the province where
12 months. Upon return, beneficiaries are required to they are available.
reside in the province for a minimum four consecutive
months. Thereafter, certificates will only be issued for Coverage is immediately discontinued when residents move
up to eight months of coverage. permanently to other countries.
■■ Students leaving the province may receive a certificate,
renewable each year, provided they submit proof of full-time
enrolment in a recognized educational institution located
outside the province.

4.4 Prior Approval Requirement surgery. Furthermore, according to the Canadian Institute
for Health Information annual report Wait Times for
Prior approval is not required for medically necessary insured Priority Procedures in Canada, Newfoundland and Labrador
services provided by accredited hospitals or licensed physicians was the only province to achieve 9 out of 10 (90 percent)
in the other provinces and territories. However, physicians may benchmark results compared to the rest of Canada in which
seek advice on coverage from the MCP so that patients may be 8 out 10 (80 percent) patients are receiving access to priority
made aware of any financial implications. benchmark procedures.
Prior approval is mandatory in order to receive funding at host Through the actions of the joint replacement strategy,
country rates if a resident of the province has to seek specialized Newfoundland and Labrador continues to be a national leader
hospital care outside the country because the insured service is with the shortest wait times in the country for hip and knee
not available in Canada. The referring physicians must contact replacement surgery. Since Newfoundland and Labrador’s
the Department for prior approval. If prior approval is granted, strategy was released (2012), we have seen a 34 percent increase
the provincial health insurance plan will pay the costs of insured (from 60 to 94 percent) in the number of knee replacement
services necessary for the patient’s care. Prior approval is not surgeries being completed within the 182 day benchmark.
granted for out-of-country treatment or elective services if the
service is available in the province or elsewhere within Canada. During the fourth quarter of 2014–2015 (January 1 to
If the services are not available in Newfoundland and Labrador, March 31, 2015), wait time reports demonstrated that,
they are usually paid at Ontario rates, or at rates that apply in on average, 94 percent of residents of Newfoundland and
the province where they are available. Labrador received timely access to benchmark procedures
within the recommended targets. The national benchmark
is 90 percent.
5.0 ACCESSIBILITY We are improving Emergency Departments to ensure there
are shorter wait times and patients are assessed and treated
in a timely manner. Through the actions of the Provincial
5.1 Access to Insured Health Services Emergency Department Wait Time Strategy, external reviews
were carried out at four additional Emergency Departments
Access to insured health services in Newfoundland and
in the province. We have now completed external reviews in
Labrador is provided on uniform terms and conditions. There
10 of our 13 Category A emergency departments. Through these
are no co-insurance charges for insured hospital services and
reviews, a variety of initiatives were undertaken to improve
there is no extra-billing by physicians in the province.
wait times, including Nurse First triage, alignment of staffing
The Department of Health and Community Services allocations to meet peak patient demand; implementation of
works closely with post-secondary educational institutions fast track units to treat low acuity patients, implementation of
within the province to maintain an appropriate supply of a Rapid Assessment Zone (RAZ) at Health Sciences Center
health professionals. The province also works with external to expedite assessment and treatment of urgent (Canadian
organizations for health professionals not trained in this Triage Acuity Scale Level 3) patients, and use of the provincial
province. Targeted recruitment incentives are in place to HealthLine to carry out follow-up contact with patients who
attract health professionals. Several programs have been left without being seen. As a result of this work, we are seeing
established to provide targeted sign-on bonuses, bursaries, reductions in the time for physician initial assessment (PIA) and
opportunities for upgrading, and other incentives for a wide the number of patients leaving without being seen (LWBS).
variety of health occupations.
Government invested $2 million in Budget 2014 to address
Newfoundland and Labrador continues to be a national endoscopy wait times and wait lists. As a result of our
leader in wait time improvements. The key drivers of these partnership with Canadian Association of Gastroenterologists
improvements are the implementation of actions under three (CAG) and the leadership of the physicians and administration
provincial strategies: the Provincial Emergency Department in the four regional health authorities (RHAs), the province
Wait Time Strategy; the Provincial Hip and Knee Joint was and is still the first and only province in Canada in which
Replacement Wait Time Strategy, which included increased 100 percent (12/12) of endoscopy suites are enrolled in the
Provincial Government funding to complete additional joint CAG Quality Program and have completed the Canadian
replacement surgeries; and the Provincial Endoscopy Wait Global Rating Scale. Additionally, the department continued
Time Strategy. its work with the Eastern Regional Health Authority in
partnership with CAG to implement the Skills Enhancement
Newfoundlanders and Labradorians continue to have in Endoscopy (SEE) program in the province in 2014. As a
some of the shortest benchmark wait times in the country. result of this work, Eastern Regional Health Authority has
Newfoundland and Labrador is ranked as the best in Canada become a designated training site for the SEE program.
in the wait times for hip and knee replacement and cataract

5.2 Physician Compensation Throughout the fiscal year, the RHAs forwarded additional
funding requests to the Department for any changes in
The legislation governing payments to physicians and program areas or increased workload volume. These requests
dentists for insured services is the Medical Care Insurance were reviewed and, when approved by the Department, funded
Act, 1999. Compensation agreements are negotiated between at the end of each fiscal year. Any adjustments to the annual
the provincial government and the Newfoundland and funding level, such as for additional approved positions or
Labrador Medical Association (NLMA), on behalf of all program changes, were funded based on the implementation
physicians. Representatives from the RHAs play a role in date of such increases and the cash flow requirements.
this process. A Memorandum of Agreement was reached
with the NLMA in December 2010, which increased overall
physician compensation by approximately 26 percent. The 6.0 RECOGNITION GIVEN TO
Agreement expired on September 30, 2013 but remains
in effect until such time as a new agreement is negotiated. FEDERAL TRANSFERS
Physicians are paid via fee-for-service, salary or alternate
Funding provided by the federal government through the
payment plan (APP) with an increasing interest in APPs
Canada Health Transfer (CHT) and the Canada Social
as a method of remuneration by physicians.
Transfer (CST) has been recognized and reported by the
Government of Newfoundland and Labrador in the annual
provincial budget, through press releases, government websites
5.3 Payments to Hospitals and various other documents. For fiscal year 2014–2015, these
The Department is responsible for funding RHAs for ongoing documents include:
operations and capital acquisitions. Funding for insured
■■ the 2014–2015 Public Accounts;
services is provided to the RHAs as an annual global budget.
Payments are made in accordance with the Hospital Insurance ■■ the Estimates 2014–2015; and
Agreement Act and the Regional Health Authorities Act. As ■■ the Budget Speech 2014–2015.
part of their accountability to the government, the health
authorities are required to meet the Department’s annual The Public Accounts and Estimates, tabled by the Government
reporting requirements, which include audited financial in the House of Assembly, are publicly available and are shared
statements and other financial and statistical information. with Health Canada for information purposes.
The global budgeting process devolves the budget allocation
authority, responsibility, and accountability to all appointed
boards in the discharge of their mandates.

REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
1. Number as of March 31st (#). 523,508 527,714 530,521 532,177 533,156
INSURED HOSPITAL SERVICES WITHIN OWN PROVINCE OR TERRITORY

Public Facilities 2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
2. Number (#). 51 51 51 51 51
3. Payments for insured health services ($). 1,028,697,016 1,088,392,487 1,097,535,388 1,100,291,277 1,131,546,830
Private For-Profit Facilities 2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
4. Number of private for-profit facilities

providing insured health services (#). 1 1 1 1 1
5. Payments to private for-profit facilities

for insured health services ($). 660,625 697,375 845,280 916,696 914,135
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
6. Total number of claims, in-patient (#). 1,632 1,648 1,844 1,574 1,773
7. Total payments, in-patient ($). 21,096,749 17,507,684 19,988,002 20,969,617 22,423,411
8. Total number of claims, out-patient (#). 23,156 23,482 27,681 22,429 26,671
9. Total payments, out-patient ($). 7,214,089 7,216,918 8,827,387 8,109,628 9,147,633
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA

10. Total number of claims, in-patient (#). 97 126 108 127 141
11. Total payments, in-patient ($). 318,203 224,822 139,270 451,834 207,198
12. Total number of claims, out-patient (#). 445 475 410 445 570
13. Total payments, out-patient ($). 209,257 91,089 96,116 105,448 71,574

INSURED PHYSICIAN SERVICES WITHIN OWN PROVINCE OR TERRITORY

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
14. Number of participating physicians (#).1 1,096 1,115 1,155 1,183 1,210
15. Number of opted-out physicians (#). 0 0 0 0 0
16. Number of not participating physicians (#). 0 0 0 0 0
17. Total payments for services provided

by physicians paid through all payment
methods ($). not available not available not available not available not available
18. Total payments for services provided by

physicians paid through fee-for-service ($). 216,931,000 218,561,000 236,529,000 251,281,302 294,572,803
INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY 2

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
19. Number of services (#). 155,000 154,000 114,000 114,000 106,000
20. Total payments ($). 6,665,000 6,627,000 6,762,000 6,954,000 6,836,000
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA

22. Total payments ($). 202,000 237,000 231,000 266,000 223,000
INSURED SURGICAL-DENTAL SERVICES WITHIN OWN PROVINCE OR TERRITORY

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
23. Number of participating dentists (#). 29 25 25 26 19
24. Number of services provided (#). 1,093 2,222 2,880 1,585 1,709
25. Total payments ($). 158,000 329,000 455,780 203,610 279,350
1. Excludes inactive physicians.Total salaried and fee-for-service.

2. Numbers are rounded to the nearest thousand.

PRINCE EDWARD ISLAND
INTRODUCTION The Department of Health and Wellness is responsible

for providing policy, strategic and fiscal leadership for the
In Prince Edward Island (PEI) the Department of Health and healthcare system, while Health PEI is responsible for service
Wellness is responsible for providing policy, strategic, and fiscal delivery and the operation of hospitals, health centres, manors
leadership for the healthcare system. and mental health facilities. Health PEI is responsible for the
hiring of physicians, while the Public Service Commission
The Health Services Act provides the regulatory and administrative of PEI hires nurse practitioners, nurses and all other health
frameworks for improvements to the healthcare system in related workers.
PEI by:
■■ mandating the creation of a provincial health plan; 1.2 Reporting Relationship

■■ establishing mechanisms to improve patient safety and
An annual report is submitted by the Department to the
support quality improvement processes; and
Minister responsible who tables it in the Legislative Assembly.
■■ creating a Crown corporation (Health PEI) to oversee the The report provides information about the operating principles
delivery of operational healthcare services. of the Department and its legislative responsibilities, as
well as an overview and description of the operations of the
Within this governance structure Health PEI has the departmental divisions and statistical highlights for the year.
responsibility to:
Health PEI prepares an annual business plan which functions
■■ provide, or provide for the delivery of, health services; as a formal agreement between Health PEI and the Minister
■■ operate and manage health facilities; responsible, and documents accomplishments to be achieved
over the coming fiscal year.
■■ manage the financial, human and other resources necessary
to provide health services and operate health facilities; and
■■ perform such other duties as the Minister may direct. 1.3 Audit of Accounts
The provincial Auditor General conducts annual audits of the
1.0 PUBLIC ADMINISTRATION public accounts of PEI. The public accounts of the province
include the financial activities, revenues and expenditures of the
Department of Health and Wellness.
1.1 Health Care Insurance Plan and The provincial Auditor General, through the Audit Act, has the
Public Authority discretion to conduct further audit reviews on a comprehensive
or program specific basis.
The Hospital Services Insurance Plan, under the authority of the
Minister of Health and Wellness, is the vehicle for delivering
hospital care insurance in Prince Edward Island (PEI). The
enabling legislation is the Hospital and Diagnostic Services
Insurance Act (1988). The Medical Services Insurance Plan
provides for insured physician services under the authority of the
Health Services Payment Act (1988). Together, the Plans insure
services as defined under section 2 of the Canada Health Act.

CHAPTER 3: PRINCE EDWARD ISLAND
2.0 COMPREHENSIVENESS they are required to inform the Minister thereof and the total
charge is made to the patient for the service rendered.
As of March 31, 2015, no physicians had opted out of the

2.1 Insured Hospital Services Medical Services Insurance Plan.
Insured hospital services are provided under the Hospital and Any basic health services rendered by physicians that are
Diagnostic Services Insurance Act (1988). The accompanying medically required are covered by the Medical Services
regulations define the insured in-patient and out-patient Insurance Plan. These include most physicians’ services in
hospital services available at no charge to a person who is the office, at the hospital or in the patient’s home; medically
eligible. Insured hospital services include, but are not limited necessary surgical services, including the services of anaesthetists
to: necessary nursing services; laboratory, radiological and other and surgical assistants where necessary; obstetrical services,
diagnostic procedures; accommodations and meals at a standard including pre-natal and post-natal care, newborn care or any
ward rate; formulary drugs, biologicals and related preparations complications of pregnancy such as miscarriage or caesarean
prescribed by an attending physician and administered in section; certain oral surgery procedures performed by an oral
hospital; operating room, case room and anaesthetic facilities; surgeon when it is medically required, with prior approval that
routine surgical supplies; and radiotherapy and physiotherapy they be performed in a hospital; sterilization procedures, both
services performed in hospital. female and male; treatment of fractures and dislocations; and
certain insured specialist services, when properly referred by
The process to add a new hospital service to the list of insured
an attending physician.
services involves extensive consultation and negotiation
between the Department, Health PEI and key stakeholders. The process to add a physician service to the list of insured services
The process involves the development of a business plan which, involves negotiation between the Department, Health PEI and
when approved by the Minister, would be taken to Treasury the Medical Society. The process involves development of a
Board for funding approval. Executive Council (Cabinet) has business plan which, when approved by the Minister, would be
the final authority in adding new services. taken to Treasury Board for funding approval. Insured physician
services may also be added or deleted as part of the negotiation of
a new Master Agreement with physicians (Section 5.2). Cabinet
2.2 Insured Physician Services has the final authority in adding new services.
The enabling legislation that provides for insured physician
services is the Health Services Payment Act (1988).
2.3 Insured Surgical-Dental Services
Insured physician services are provided by medical practitioners
Dental services are not insured under the Medical Services
licensed by the College of Physicians and Surgeons. The total
Insurance Plan. Only oral maxillofacial surgeons are paid
number of practicing practitioners who billed the Medical
through the Plan. There are currently two surgeons in that
Services Insurance Plan as of March 31, 2015 was 331.
category. Surgical-dental procedures included as basic health
This includes all physicians (complement, locums, visiting
services in the Tariff of Fees are covered only when the
specialists, and other non-complement physicians). Prior to
patient’s medical condition requires that they be done in
2012–2013, Prince Edward Island (PEI) reported complement
hospital or in an office with prior approval, as confirmed by
physicians only.
the attending physician.
Under section 10 of the Health Services Payment Act, a
physician or practitioner who is not a participant in the
Medical Services Insurance Plan is not eligible to bill the Plan 2.4 Uninsured Hospital, Physician and
for services rendered. When a non-participating physician Surgical-Dental Services
provides a medically required service, section 10(2) requires
that physicians advise patients that they are non-participating Services not covered by the Hospital Services Insurance
physicians or practitioners and provide the patient with Plan include:
sufficient information to enable recovery of the cost of services
from the Minister of Health and Wellness. Under section 10.1 ■■ services that persons are eligible for under other provincial
of the Health Services Payment Act, a participating physician or federal legislation;
or practitioner may determine, subject to and in accordance ■■ mileage or travel, unless approved by Health PEI;
with the regulations and in respect of a particular patient or a
■■ telephone consultation except by internists, palliative care
particular basic health service, to collect fees outside the Plan
physicians, paediatricians, out-of-province specialists, and
or selectively opt out of the Plan. Before the service is rendered,
orthopaedic surgeons, provided the patient was not seen by
patients must be informed that they will be billed directly for
that physician within 3 days of the telephone consult;
the service. Where practitioners have made that determination,

■■ examinations required in connection with employment,

insurance, education, etc.;
3.0 UNIVERSALITY
■■ group examinations, immunizations or inoculations, unless
prior approval is received from Health PEI; 3.1 Eligibility
■■ preparation of records, reports, certificates or communications,
The Health Services Payment Act and Regulations, section 3,
except a certificate of committal to a psychiatric, drug or
define eligibility for the Medical Services Insurance Plan. This
alcoholism facility;
Plan is designed to provide coverage for eligible Prince Edward
■■ testimony in court; Island (PEI) residents. A resident is anyone legally entitled
■■ travel clinic and expenses; to remain in Canada and who makes his or her home and is
ordinarily present on an annual basis for at least six months
■■ surgery for cosmetic purposes unless medically required; plus a day, in PEI.
■■ dental services other than those procedures included as basic
health services; All new residents must register with the Department in order to
become eligible. Persons who establish permanent residence in
■■ dressings, drugs, vaccines, biologicals and related materials; PEI from elsewhere in Canada will become eligible for insured
■■ eyeglasses and special appliances; hospital and medical services on the first day of the third month
following the month of arrival.
■■ chiropractic, podiatry, optometry, chiropody, osteopathy,
naturopathy, and similar treatments; Residents who are ineligible for insured hospital and medical
■■ physiotherapy, psychology, and acupuncture except when services coverage in PEI are those who are eligible for certain
provided in hospital; services under other federal or provincial government programs,
such as members of the Canadian Forces, inmates of federal
■■ reversal of sterilization procedures;
penitentiaries, and clients of Workers’ Compensation or the
■■ in vitro fertilization; Department of Veterans Affairs’ programs.
■■ services performed by another person when the supervising
Ineligible residents may become eligible in certain
physician is not present or not available;
circumstances. For example, members of the Canadian Forces
■■ services rendered by a physician to members of the become eligible on discharge or completion of rehabilitative
physician’s own household, unless approval is obtained leave. Penitentiary inmates become eligible upon release. In
from Health PEI; and such cases, the province where the individual in question was
■■ any other services that the Department may, upon the stationed at the time of discharge or release, or release from
recommendation of the negotiation process between the rehabilitative leave, would provide initial coverage during the
Department, Health PEI and the Medical Society, declare customary waiting period of up to three months. Parolees
non-insured. from penitentiaries will be treated in the same manner as
discharged prisoners.
Hospital services not covered by the Hospital Services Insurance
Plan include private or special duty nursing at the patient’s or New or returning residents must apply for health coverage
family’s request; preferred accommodation at the patient’s request; by completing a registration application from HealthPEI.
hospital services rendered in connection with surgery purely for The application is reviewed to ensure that all necessary
cosmetic reasons; personal conveniences, such as telephones and information is provided. A health card is issued and sent to
televisions; drugs, biologicals and prosthetic and orthotic appli- the resident within two weeks. Renewal of coverage takes place
ances for use after discharge from hospital; and dental extractions, every five years and residents are notified by mail six weeks
except in cases where the patient must be admitted to hospital for before renewal.
medical reasons with prior approval of Health PEI.
The number of residents registered with the Medical Services
The process to de-insure services covered by the Medical Insurance Plan in PEI as of March 31, 2015, was 146,170.
Services Insurance Plan is done in collaboration with the
Medical Society, Health PEI and the Department. No services
were de-insured during the 2014–2015 fiscal year. 3.2 Other Categories of Individuals
All PEI residents have equal access to services. Third parties Foreign students, tourists, transients or visitors to PEI do
such as private insurers or the Workers’ Compensation Board not qualify as residents of the province and are, therefore,
of PEI do not receive priority access to services through not eligible for hospital and medical insurance benefits.
additional payment.
Temporary workers, refugees and Minister’s Permit holders
PEI has no formal process to monitor compliance; however, are not eligible for hospital and medical insurance benefits.
feedback from physicians, hospital administrators, medical
professionals and staff allows the Department and Health PEI
to monitor usage and service concerns.

4.0 PORTABILITY 4.4 Prior Approval Requirement

Prior approval is required from Health PEI before receiving
non-emergency, out-of-province medical or hospital services.
4.1 Minimum Waiting Period Island residents seeking such required services may apply for
Insured persons who move to Prince Edward Island (PEI) are prior approval through a PEI physician. Full coverage may be
eligible for health insurance on the first day of the third month provided for (PEI insured) non-emergency or elective services,
following the month of arrival in the province. provided the physician completes an application to Health PEI.
Prior approval is required from the Medical Director of Health
PEI to receive out-of-country hospital or medical services not
4.2 Coverage During Temporary Absences available in Canada.
in Canada
Residents absent each year for any reasons must reside in PEI 5.0 ACCESSIBILITY
for at least six months plus a day each year in order to be eligible
for sudden illness and emergency services while absent from
the province, as allowed under section 11 of the Health Services 5.1 Access to Insured Health Services
Payment Act. A person, including a student, who is temporarily
Both of Prince Edward Island’s (PEI) hospital and medical
absent from the province for up to 182 days in a 12 month
services insurance plans provide services on uniform terms
period must notify Health PEI before leaving.
and conditions on a basis that does not impede or preclude
PEI participates in the Hospital Reciprocal Billing Agreement reasonable access to those services by insured persons.
and the Medical Reciprocal Billing Agreement along with
PEI has a publicly administered and funded health system that
other jurisdictions across Canada.
guarantees universal access to medically necessary hospital and
physician services as required by the Canada Health Act.
4.3 Coverage During Temporary Absences PEI recognizes that the health system must constantly adapt
Outside Canada and expand to meet the needs of our citizens. Several examples
of initiatives from the 2014–2015 fiscal year include:
The Health Services Payment Act is the enabling legislation
that defines portability of health insurance during temporary ■■ PEI opened a new provincial palliative care centre which
absences outside Canada, as allowed under section 11. provides patients with more care options and their loved
ones the opportunity to be involved in care.
Persons must reside in PEI for at least six months plus a
■■ Investments were made to expand the newborn screening
day each year in order to be eligible for sudden illness and
program, doubling the number of conditions and blood
emergency services while absent from the province, as allowed
disorders covered. The program also will provide a full range
under section 11 of the Health Services Payment Act.
of services beyond screening, such as arranging follow-up
Insured residents may be temporarily out of the country for up appointments, clinical visits and referral to specialists for
to a 12 month period in some circumstances. patients who test positive for a condition.
■■ PEI implemented an Out-of-Province Travel Support
Students attending a recognized learning institution in another Program to provide assistance to eligible Island residents
country must provide proof of enrolment from the educational for travel on Maritime Bus to approved health care services
institution on an annual basis. Students must notify Health within the Maritime Provinces.
PEI upon returning from outside the country.
■■ A new addictions transition unit opened as part of
For PEI residents leaving the country for work purposes for Government’s action plan to enhance addiction services
longer than one year, coverage ends the day the person leaves. for Islanders.
■■ Significant investments were made to increase and enhance
For Island residents travelling outside Canada, coverage for
services to children with complex needs. Services to be
emergency or sudden illness will be provided at PEI rates only,
enhanced include pediatric occupational and physiotherapy,
in Canadian currency. Residents are responsible for paying the
orthoptics, preschool autism assessments, and speech
difference between the full amount charged and the amount
language pathology and audiology.
paid by the Department.

As PEI is primarily a rural province where a large segment of 5.3 Payments to Hospitals
the population resides outside the main service centres, local
access to health services, including acute services delivered Payments (advances) to provincial hospitals and community
through community hospitals and health centres, is important hospitals for hospital services are approved for disbursement
to small communities. PEI continues to expand health by the Department in line with cash requirements and are
infrastructure necessary to support health service delivery subject to approved budget levels.
in rural communities.
The usual funding method includes using a global budget
adjusted annually to take into consideration increased costs
5.2 Physician Compensation related to such items as labour agreements, drugs, medical
supplies and facility operations.
A collective bargaining process is used to negotiate physician
compensation. Bargaining teams are appointed by both
physicians and the government to represent their interests
in the process. The current five-year Physician Master
6.0 RECOGNITION GIVEN TO
Agreement between the PEI Medical Society, on behalf of FEDERAL TRANSFERS
Island physicians, the Department of Health and Wellness,
and Health PEI is effective April 1, 2010 to March 31, 2015. The Government of Prince Edward Island strives to recognize
Negotiations for the new Master Agreement will begin in the the federal contributions provided through the Canada Health
fall of 2015. Transfer whenever appropriate. Over the past year, this has
included reference in public documents such as the Province of
The legislation governing payments to physicians and dentists PEI 2014–2015 Annual Budget and in the 2014–2015 Public
for insured services is the Health Services Payment Act. Accounts, which both were tabled in the Legislative Assembly
and are publicly available to Prince Edward Island residents.
Many physicians continue to work on a fee-for-service basis;
however, alternate payment plans have been developed and It is also the intent of the Department of Health and Wellness
some physicians receive salary, contract and sessional payments. to recognize this important contribution in its 2014–2015
Alternate payment modalities are expanding and seem to be Annual Report.
the preference for new graduates. Currently, 63 percent of
PEI’s physicians (excluding locums and visiting specialists) are
compensated under an alternate payment method (non-fee-for-
service) as their primary means of remuneration.

REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

2. Number (#). 7 7 7 7 7
3. Payments for insured health services ($). 172,100,500 183,647,900 192,480,600 197,008,800 206,026,400


for insured health services ($). 0 0 0 0 0

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015



2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
14. Number of participating physicians (#).1 242 232 344 318 331

methods ($). 62,670,303 2
60,719,582 2
65,193,465 2
67,973,102 2
70,045,760 2

INSURED PHYSICIAN SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 6,247,907 6,330,440 7,025,721 9,567,703 9,868,637

21. Number of services (#). 684 950 1,109 659 390
22. Total payments ($). 31,729 40,600 38,036 38,005 37,500

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
24. Number of services provided (#). 352 377 383 361 446
25. Total payments ($). 137,566 125,392 125,290 130,393 169,386
1. Prior to 2012–2013, the total does not include locums, visiting specialists or other non-complement physicians.
2. Prior to 2012–2013, data reported did not capture full comprehensive clinical payments. The reporting mechanism has been corrected such that all relevant
clinical payments are captured and presented in 2012–2013.

NOVA SCOTIA
INTRODUCTION enhanced pharmaceutical coverage. Nova Scotia also has

much higher than average rates of chronic diseases such as
The Nova Scotia Department of Health and Wellness’s vision cancers and diabetes which contribute to the rising costs of
and mission are: health care delivery.
■■ Vision: Healthy People, Healthy Communities for Despite these ever increasing pressures and challenges,
Generations Nova Scotia continues to be committed to the delivery of
medically necessary services consistent with the principles
■■ Mission: Working together to achieve excellence in of the Canada Health Act.
health, healing and learning
Additional information related to health care in Nova Scotia
The health and wellness system includes the delivery of health may be obtained from the Department of Health and Wellness
care as well as the prevention of disease and injury and the website at http://novascotia.ca/DHW.
promotion of health and healthy living. The Department is
responsible for the following core program areas: mental health
and addiction services; partnerships and physician services;
pharmaceutical programs; primary health care; emergency
1.0 PUBLIC ADMINISTRATION
health services; continuing care; acute and tertiary care; health
system workforce; health care quality; public health; health
services emergency management; health information and
1.1 Health Care Insurance Plan and
active living. Public Authority
On April 1, 2015, Nova Scotia will implement amendments Two plans cover insured health services in Nova Scotia:
to the Health Authorities Act. The amendments will provide for the Hospital Insurance and the Medical Services Insurance
new roles for the Minister of Health and Wellness and the (MSI) Plans.
health authorities. The amendments will also provide for the
establishment of the Nova Scotia Health Authority, which The Department of Health and Wellness administers the
is a consolidation of nine former district health authorities. Hospital Insurance Plan, which operates under the Health
The Minister of Health and Wellness will be responsible Services and Insurance Act, Chapter 197, Revised Statutes of
for: providing leadership for the health system by setting the Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18 and 35.
strategic policy direction, priorities and standards for the The MSI Plan is administered and operated by an authority
health system; and ensuring accountability for funding and for consisting of the Department of Health and Wellness and
the measuring and monitoring of health system performance. Medavie Blue Cross Incorporated, under the above-mentioned
The health authorities (Nova Scotia Health Authority and Act (sections 8, 13, 17(2), 23, 27, 28, 29, 30, 31, 32 and 35).
the Izaak Walton Killam Health Centre — NSHA & IWK
respectively) will be responsible for: governing, managing and Section 8 of the Act gives the Minister of Health and Wellness,
providing health services in the Province and implementing with approval of the Governor in Council, the power to
the strategic direction set out in the provincial health plan; enter into agreements and vary, amend or terminate the same
and engaging with the communities they serve, through the agreements with such person or persons as the Minister deems
community health boards. necessary to establish, implement and carry out the MSI Plan.
Nova Scotia faces a number of challenges in the delivery The Department of Health and Wellness and Medavie Blue
of health care services. Nova Scotia’s population is Cross Incorporated entered into a service level agreement,
aging. Approximately 18.9 percent of the Nova Scotian effective August 1, 2005. Under the agreement, Medavie
population is 65 or older; this figure is expected to reach Blue Cross Incorporated is responsible for operating and
28.1 percent by 2030. In response to the needs of the aging administering programs contained under MSI, Pharmacare
population, Nova Scotia has expanded its basket of publicly Programs and Health Card Registration Services.
insured services to include home care, long term care, and

CHAPTER 3: NOVA SCOTIA
1.2 Reporting Relationship health card administration, physician claims activity, financial
monitoring, provider management, audit activities and program
In the service level agreement, Medavie Blue Cross Incorporated utilization. These reports are submitted on a monthly, quarterly,
is obliged to provide reports to the Department under various or annual basis. A complete list of reports can be obtained from
Statements of Requirements for each Business Service the Nova Scotia Department of Health and Wellness.
Description as listed in the contract. Medavie Blue Cross
Incorporated is audited every year on various areas of reporting. As part of an agreement with the Department of Health and
Wellness, QSI also provides monthly, quarterly, and annual
Section 17(1)(i) of the Health Services and Insurance Act, and reports with regard to dental programs in Nova Scotia. This
sections 11(1) and 12(1) of the Hospital Insurance Regulations, includes dental services provided in-hospital as outlined in
under this Act, set out the terms for reporting by hospitals and the Canada Health Act. These reports address provider claims
hospital boards to the Minister of Health and Wellness. and payment, program utilization, and audit. A complete list
of reports can be obtained from the Nova Scotia Department
of Health and Wellness.
1.3 Audit of Accounts
The Auditor General audits all expenditures of the Department
of Health and Wellness. Under its service level agreement with
2.0 COMPREHENSIVENESS
the Department of Health and Wellness, Medavie Blue Cross
Incorporated provides audited financial statements of MSI 2.1 Insured Hospital Services
costs to the Department of Health and Wellness. The Auditor
General and the Department of Health and Wellness have the Nine district health authorities and the Izaak Walton Killam
right to perform audits of the administration of the agreement (IWK) Health Centre — a women and children’s tertiary care
with Medavie Blue Cross Incorporated. hospital — deliver insured hospital services to both in-patients
and out-patients in Nova Scotia. The process for transitioning
All long-term care facilities, home care and home support from nine provincial health authorities to one (Nova Scotia
agencies are required to provide the Department of Health and Health Authority) began in 2014–2015 and will officially be
Wellness with annual audited financial statements. in place April 1, 2015.
Under section 34(5) of the Health Authorities Act, every hospital Accreditation is not mandatory, but all facilities are accredited
board is required to submit to the Minister of Health and at a facility or district level. The enabling legislation that
Wellness, by July 1st each year, an audited financial statement provides for insured hospital services in Nova Scotia is the
for the preceding fiscal year. Health Services and Insurance Act, Chapter 197, Revised Statutes
of Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18
and 35, passed by the Legislature in 1958. Hospital Insurance
1.4 Designated Agency Regulations were made pursuant to the Health Services and
Insurance Act.
Medavie Blue Cross Incorporated administers and has the
authority to receive monies to pay physician accounts under the The Insured Health Services Act was passed in December 2012,
service level agreement with the Department of Health and but has not yet been proclaimed. It will replace the current
Wellness. Medavie Blue Cross Incorporated receives written Health Services and Insurance Act which provides the statutory
authorization from the Department of Health and Wellness framework for health insurance programs in Nova Scotia.
to make these payments. The rates of pay and specific amounts The new Act aims to modernize existing legislation (in place
depend on the physician contract negotiated between Doctors since 1973) and it commits to the principles of the Canada
Nova Scotia and the Department of Health and Wellness. Health Act with the intent of ensuring equitable access to
insured health services.
The Department of Health and Wellness and the Office of the
Auditor General, have the right, under the terms of the service Under the Hospital Services Insurance Plan, in-patient
level agreement, to audit all MSI and Pharmacare transactions. services include:
Quikcard Solutions Incorporated (QSI) administers and has the ■■ accommodation and meals at the standard ward level;
authority to receive monies to pay dentists under a service level
agreement with the Department of Health and Wellness. The ■■ necessary nursing services;
tariff of dental fees is negotiated between the Nova Scotia Dental ■■ laboratory, radiological and other diagnostic procedures;
Association and the Department of Health and Wellness.
■■ routine surgical supplies;
Medavie Blue Cross Incorporated is responsible for providing ■■ use of operating room(s), case room(s) and anaesthetic
approximately 85 reports to the Department pertaining to services;

■■ use of radiotherapy and physiotherapy services for in-patients, Insured services include those that are medically necessary.
where available; and Medically necessary may be defined as services provided by
■■ blood or therapeutic blood fractions. a physician to a patient with the intent to diagnose or treat
physical or mental disease or dysfunction, as well as those
Out-patient services include: services generally accepted as promoting health through
prevention of disease or dysfunction. Services that are not
■■ laboratory and radiological examinations; medically necessary are not insured. Services explicitly deemed
■■ diagnostic procedures involving the use of as non-insured under the Health Services and Insurance Act
radio-pharmaceuticals; or its regulations remain uninsured regardless of individual
judgments regarding the medical necessity.
■■ electroencephalographic examinations;
■■ use of occupational and physiotherapy facilities, Additional services were added to the list of insured physician
where available; services in 2014–2015. A complete list can be obtained from
the Nova Scotia Department of Health and Wellness. On an as
■■ necessary nursing services; needed basis, new specific fee codes are approved that represent
■■ drugs, biologicals and related preparations; enhancements, new technologies or new ways of delivering
a service.
■■ blood or therapeutic blood fractions;
■■ hospital services in connection with most minor medical The addition of new fee codes, or adjustment to existing fee
and surgical procedures; codes, to the list of insured physician services is accomplished
through a collaborative Department of Health and Wellness,
■■ day-patient diabetic care;
Health Authority and Doctors Nova Scotia committee
■■ services provided by the Nova Scotia Hearing and structure. Physicians wishing to have a new fee code added
Speech Clinics, where available; to the MSI Physician Manual submit a formal application to
■■ ultrasonic diagnostic procedures; the Fee Schedule Advisory Committee (FSAC) for review.
Each request is thoroughly researched. FSAC then makes a
■■ home parenteral nutrition, where available; and recommendation to the Master Agreement Steering Group
■■ haemodialysis and peritoneal dialysis, where available. (MASG) which either approves or denies the proposal. The
MASG Committee is comprised of equal representation
Each year district health authorities and the IWK Health from Doctors Nova Scotia and the Department of Health
Centre submit business plans outlining budgets and and Wellness. If the fee is approved, Medavie Blue Cross
priorities for the coming year to ensure safe and high quality Incorporated is directed to add the new fee to the schedule
access to care. Plans are evaluated through a centralized of insured services payable by the MSI Plan.
process by the Department of Health and Wellness and
approved by Executive Council. Beginning in 2015,
under the amended Health Authorities Act, which comes 2.3 Insured Surgical-Dental Services
into force April 1, 2015, health authority business plans
will be submitted on November 1st every year and will be To provide insured surgical-dental services under the Health
approved by the Minister of Health and Wellness. Services and Insurance Act, dentists must be registered members
of the Nova Scotia Dental Association and must also be
certified competent in the practice of dental surgery. The Health
2.2 Insured Physician Services Services and Insurance Act is written so that a dentist may choose
not to participate in the MSI Plan. To participate, a dentist
The legislation covering the provision of insured physician must register with MSI. A participating dentist who wishes
services in Nova Scotia is the Health Services and Insurance Act, to reverse election to participate must advise MSI in writing
sections 3(2), 5, 8, 13, 13A, 17(2), 22, 27–31, 35 and the and is then no longer eligible to submit claims to MSI. In
Medical Services Insurance Regulations. 2014–2015, 25 dentists submitted claims through the MSI Plan
for providing insured surgical-dental services.
As of March 31, 2015, 2,580 physicians were paid through the
Medical Services Insurance (MSI) Plan. Insured surgical-dental services must be provided in a health
care facility. Insured services are detailed in the Department
Physicians retain the ability to opt in or out of the MSI Plan. of Health and Wellness MSI Dentist Manual (Dental Surgical
In order to opt out, a physician notifies MSI, relinquishing his Services Program) and are reviewed annually through the
or her billing number. MSI reimburses patients who pay the Partnerships and Physician Services Branch. Services under
physician directly due to opting out. As of March 31, 2015, this program are insured when the conditions of the patient
no physicians had opted out. are such that it is medically necessary for the procedure to be
done in a hospital and the procedure is of a surgical nature.

Generally included as insured surgical-dental services are ■■ physician’s services provided to their own families;
orthognathic surgery, surgical removal of impacted teeth, and ■■ services performed for cosmetic purposes only;
oral and maxillofacial surgery. Requests for an addition to the
list of surgical-dental services are accomplished through the ■■ group immunizations performed without receiving
Dental Association of Nova Scotia who forwards a proposal to preapproval by MSI;
the Department of Health and Wellness. Then, in consultation ■■ acupuncture;
with experts in the field, the Department renders a decision on
■■ electrolysis;
the addition of the procedure as an insured service.
■■ reversal of sterilization;
Insured services in the “Other extraction services” (routine
■■ in vitro fertilization;
extractions) category are approved for the following
groups of patients: cardiac patients, transplant patients, ■■ provision of travel vaccines;
immunocompromised patients, and radiation patients. ■■ newborn circumcision;
This is the case only when patients are undergoing
active treatment in a hospital setting and the attendant ■■ release of tongue tie in newborn;
medical procedure must require the removal of teeth that ■■ removal of cerumen, except in the case of a febrile child;
would otherwise be considered routine extractions.
■■ treatment of warts or other benign conditions of the skin;
■■ comprehensive visits when there are no signs, symptoms or
2.4 Uninsured Hospital, Physician and family history of disease or disability;
Surgical-Dental Services ■■ services, supplies and other materials not part of office
overhead, including for example, photocopying or other
Uninsured hospital services include: costs associated with transfer of records;
■■ preferred accommodation at the patient’s request; ■■ items such as drugs, dressings, and tray fees; physician’s
advice by telephone, letter, fax or email, with exceptions; and
■■ telephones;
■■ mileage or travelling time.
■■ televisions;
■■ drugs and biologicals ordered after discharge from hospital; Of note is the removal of sex reassignment surgery from the
explicit list of services that are not insured through MSI. Sex
■■ cosmetic surgery; reassignment surgery became an insured service April 1, 2014.
■■ reversal of sterilization procedures;
Major third party agencies currently purchasing medically
■■ in-vitro fertilization; necessary health services in Nova Scotia include Workers’
■■ procedures performed as part of clinical research trials; Compensation and the Department of National Defence.
■■ services such as gastric bypass for morbid obesity, breast All residents of the province are entitled to services covered
reduction/augmentation and newborn circumcision under the Health Services and Insurance Act. If enhanced goods
(These services may be insured when approved as special and services, such as foldable intraocular lens or fiberglass
consideration for medical reasons only); and casts, are offered as an alternative, the specialist or physician
■■ services not deemed medically necessary that are required is responsible to ensure that the patient is aware of their
by third parties, such as insurance companies. responsibility for the cost. Patients are not denied service based
on their inability to pay. The province provides alternatives to
Uninsured Physician Services include: any of the enhanced goods and services.
■■ services available to residents of Nova Scotia that are The Department of Health and Wellness carefully reviews all
covered under any statute or law of any other jurisdiction, patient complaints or public concerns that may indicate that the
either within or outside of Canada; general principles of insured services are not being followed.
■■ diagnostic, preventive or other physician’s services
available through the Nova Scotia Hospital Insurance If a service or procedure is deemed by the Department of
Program, the Department of Health and Wellness, or other Health and Wellness not to be medically necessary, it is
government agencies; removed from the physician fee schedule and will no longer be
reimbursed to physicians as an insured service. Once a service
■■ services at the request of a third party; has been de-insured, all procedures and testing relating to the
■■ provision of a prescription or a requisition for a diagnostic provision of that service also become de-insured. The same also
or therapeutic service provided to a patient without applies to dental services and hospital services. The last time
a clinical evaluation; there was any significant de-insurance of services was in 1997.

3.0 UNIVERSALITY Non-Canadians married to Canadian Citizens or Permanent

Residents (copy of marriage certificate required), who possess
the required documentation from Citizenship and Immigration
Canada indicating they have applied for permanent residency,
3.1 Eligibility will be eligible for coverage on the date of arrival in Nova Scotia
Eligibility for insured health care services in Nova Scotia is out- (if applied prior to their arrival to Nova Scotia), or the date of
lined under section 2 of the Hospital Insurance Regulations made application for permanent residency (if applied after their arrival
pursuant to section 17 of the Health Services and Insurance Act. in Nova Scotia).
All residents of Nova Scotia are eligible. A resident is defined as
Convention refugees or persons in need of protection who
anyone who is legally entitled to stay in Canada and who makes
possess the required documentation from Citizenship
his or her home and is ordinarily present in Nova Scotia.
and Immigration Canada indicating they have applied for
In 2014–2015, a person is considered to be “ordinarily present” permanent residency will be eligible for coverage on the date
in Nova Scotia if the person: of application for permanent residency.
■■ makes his or her permanent home in Nova Scotia; In 2014–2015, there were 37,835 permanent residents registered
with the health care insurance plan.
■■ is physically present in Nova Scotia for at least 183 days
in any calendar year (short term absences under 30 days, Refugees: Refugees are eligible for MSI once they have
within Canada, are not monitored); and been granted permanent residency status by Citizenship and
■■ is a Canadian citizen or “Permanent Resident” as defined Immigration Canada, or if they possess either a work permit
by Citizenship and Immigration Canada. or study permit.
Persons moving to Nova Scotia from another Canadian Work Permits: Persons moving to Nova Scotia from outside the
province will normally be eligible for Medical Services country who possess a work permit can apply for coverage on the
Insurance (MSI) on the first day of the third month following date of arrival in Nova Scotia, provided they will be remaining
the month of their arrival. Persons moving permanently to in Nova Scotia for at least one full year. A declaration must be
Nova Scotia from another country are eligible on the date signed to confirm that the worker will not be outside Nova Scotia
of their arrival in the province, provided they are Canadian for more than 31 consecutive days, unless required in the course
citizens or hold “Permanent Resident” status as defined by of employment. MSI coverage is extended for a maximum
Citizenship and Immigration Canada. of 12 months at a time. Each year, a copy of their renewed
immigration document must be presented and a declaration
Individuals insured under the Workers’ Compensation Act or any signed. Dependants of such persons, who are legally entitled to
other Act of the Legislature or of the Parliament of Canada, remain in Canada, are granted coverage on the same basis.
or under any statute or law of any other jurisdiction either
within or outside Canada, are not eligible for MSI coverage Once coverage has terminated, the person is to be treated as
(such as members of the Canadian Forces, federal inmates never having qualified for health services coverage as herein
and some classes of refugees). Once individuals are no longer provided and must comply with the above requirements before
covered under any of the Acts, statutes or laws noted above, coverage will be extended to them or their dependants.
they are then eligible to apply and receive Nova Scotia health
In 2014–2015, there were 3,019 individuals with Employment
insurance coverage, provided that they are either a Canadian
Authorizations covered under the health care insurance plan.
citizen or a permanent resident as defined by Citizenship and
Immigration Canada. Study Permits: Persons moving to Nova Scotia from another
country and who possess a Study Permit will be eligible for
In 2014–2015, the total number of residents registered with the
MSI on the first day of the thirteenth month following the
health insurance plan was 1,001,708.
month of their arrival, provided they have not been absent
from Nova Scotia for more than 31 consecutive days, unless
required in the course of their studies. MSI coverage is extended
3.2 Other Categories of Individuals for a maximum of 12 months at a time and only for services
Other individuals may be eligible for insured health care received within Nova Scotia. Each year, a copy of their renewed
services in Nova Scotia if they meet specific eligibility criteria immigration document must be presented and a declaration
listed below: signed. Dependants of such persons, who are legally entitled
to remain in Canada, will be granted coverage on the same basis
Immigrants: Persons moving from another country to live once the student has gained entitlement.
permanently in Nova Scotia are eligible for health care on the
date of arrival. They must possess a landed immigrant document. In 2014–2015, there were 1,467 individuals with Student
These individuals, formerly called “landed immigrants,” are now Authorizations covered under the health care insurance plan.
referred to as “permanent residents.”

4.0 PORTABILITY 4.3 Coverage During Temporary Absences

Outside Canada
4.1 Minimum Waiting Period Nova Scotia adheres to the Agreement on Eligibility and
Portability for dealing with insured services for residents
Persons moving to Nova Scotia from another Canadian temporarily outside Canada. Provided a Nova Scotia resident
province or territory will normally be eligible for Medical meets eligibility requirements, out-of-country services will be
Services Insurance (MSI) on the first day of the third month paid, at a minimum, on the basis of the amount that would
following the month of their arrival. have been paid by Nova Scotia for similar services rendered
in this province. In order to be covered, procedures of a non-
emergency nature must have prior approval before they will
4.2 Coverage During Temporary Absences be covered by MSI.
in Canada As of August 1, 2014 Nova Scotia residents are permitted out
The Interprovincial Agreement on Eligibility and Portability of country for vacation for one additional month. This allows
is followed in all matters pertaining to the portability of Nova Scotians to have a vacation outside of the country for
insured services. seven months in each calendar year and continue to be eligible
for MSI.
Generally, the Nova Scotia MSI Plan provides coverage for
residents of Nova Scotia who move to other provinces or Students and their dependants who are temporarily absent
territories for a period of three months, per the Eligibility from Nova Scotia and in full-time attendance at an educational
and Portability Agreement. Students and their dependants, institution outside Canada may remain eligible for MSI on a
who are temporarily absent from Nova Scotia and in full-time yearly basis. To qualify for MSI, the student must provide to
attendance at an educational institution, may remain eligible MSI a letter obtained from the educational institution that
for MSI on a yearly basis. To qualify for MSI, the student must verifies the student’s attendance there in each year for which
provide to MSI a letter directly from the educational institution MSI coverage is requested.
which states that they are registered as a full-time student. MSI
Persons who engage in employment (including volunteer,
coverage will be extended on a yearly basis pending receipt of
missionary work or research) outside Canada which does not
this letter.
exceed 24 months are still covered by MSI, providing the
Workers who leave Nova Scotia to seek employment elsewhere person has already met the residency requirements.
will still be covered by MSI for up to 12 months, provided
The total amount spent in 2014–2015 for insured in-patient
they do not establish residence in another province or territory.
services provided outside of Canada was $777,019. Nova Scotia
Services provided to Nova Scotia residents in other provinces
does not cover out-patient services out of country.
or territories are covered by reciprocal agreements. Nova Scotia
participates in the Hospital Reciprocal Billing Agreement and
the Medical Reciprocal Billing Agreement. Québec is the only
province that does not participate in the Medical Reciprocal
4.4 Prior Approval Requirement
Billing Agreement. Nova Scotia pays for services provided by Prior approval must be obtained for elective services outside the
Québec physicians to Nova Scotia residents at Québec rates if country. Application for prior approval is made to the Medical
the services are insured in Nova Scotia. The majority of such Director of the MSI Plan by a specialist in Nova Scotia on
claims are received directly from Québec physicians. In-patient behalf of an insured resident. The medical consultant reviews
hospital services are paid through the interprovincial reciprocal the terms and conditions and determines whether or not the
billing arrangement at the standard ward rate of the hospital service is available in the province, or if it can be provided in
providing the service. Nova Scotia pays the host province rates another province or only out-of-country. The decision of the
for insured services in all reciprocal billing situations. medical consultant is relayed to the patient’s referring specialist.
If approval is given to obtain service outside the country, the
The total amount paid by the plan in 2014–2015 for in-patient
full cost of that service will be covered under MSI.
and out-patient hospital services received in other provinces and
territories was $31,336,298.
As of August 1, 2014 Nova Scotia residents are permitted out

of province for vacation for one additional month. This allows
Nova Scotians to have a vacation outside of the province for
seven months in each calendar year and continue to be eligible
for MSI.

5.0 ACCESSIBILITY In the 1997–1998 fiscal year, about 9 percent of doctors

were paid solely through alternative funding. In 2014–2015,
approximately 24 percent of physicians were remunerated
exclusively through alternative funding. Approximately
5.1 Access to Insured Health Services 65 percent of physicians in Nova Scotia receive all or a portion
Section 3 of the Health Services and Insurance Act states that of their remuneration through alternative funding mechanisms
subject to this Act and the regulations, all residents of the such as academic funding agreements with clinical departments
province are entitled to receive insured hospital services from for the provision of clinical, academic, administrative and
hospitals on uniform terms and conditions. As well, all residents research services; alternative payment plans for individual
of the province are insured on uniform terms and conditions in physicians and groups used mostly in rural areas; and other
respect of the payment of insured professional services to the funding programs such as emergency agreements and
extent of the established tariff. There are no user charges or sessional funding.
extra charges allowed under the plan.
Payment rates for dental services in the province are negoti-
Nova Scotia continually reviews access situations across ated between the Department of Health and Wellness and the
Canada to ensure equity of access. In areas where improvement Nova Scotia Dental Association following a process similar to
is deemed necessary, depending on the province’s financial physician negotiations. Dentists are generally paid on a fee-
situation, extra funding is generally allocated to that need. for-service basis, pediatric dentists at the IWK Health Centre
receive remuneration through an Academic Funding Plan.
Eight Collaborative Emergency Centers (CECs) are now
open to provide Nova Scotians living in smaller communities
expanded access to primary health care, same day or next day 5.3 Payments to Hospitals
access to appointments and 24/7 access to emergency care.
Emergency Department closures have been significantly The Department of Health and Wellness establishes budget
reduced at CEC sites. The Department has worked with system targets for health care services. It does this by receiving business
partners to address several other areas of health care access. The plans from the nine district health authorities (DHAs), the
current focus is the introduction of Emergency Care Standards IWK Health Centre and other non-DHA organizations.
across the province. Approved provincial estimates form the basis on which
payments are made to these organizations for service delivery.
The province committed to begin a process of transitioning
from nine district health authorities to one provincial health The Health Authorities Act was given Royal Assent on
authority. The new structure will create a health system that is June 8, 2000. The Act instituted the nine DHAs and the
focused on province-wide solutions. This new structure will be IWK that replaced the former regional health boards. The
in place by April 1, 2015. DHAs and the IWK are responsible for overseeing the delivery
of health services in their districts, and are fully accountable
Alternative Payment Plans for physicians continued to be for explaining their decisions on the community health plans
implemented and/or expanded to improve recruitment in rural through their business plan submissions to the Department
and hard-to-fill areas, improving access to primary health care of Health and Wellness. The Act has been amended and the
in those communities. changes will come into force April 1, 2015. The amendments
provide for the consolidation of the nine district health
authorities into one provincial health authority, the Nova Scotia
5.2 Physician Compensation Health Authority (NSHA). The IWK will remain as a health
authority. The NSHA and IWK will be required to work
The Health Services and Insurance Act, RS Chapter 197 governs collaboratively in delivering services to Nova Scotians.
payment to physicians and dentists for insured services.
Physician payments are made in accordance with a negotiated Section 10 of the Health Services and Insurance Act and sections 9
agreement between Doctors Nova Scotia (the sole bargaining through 13 of the Hospital Insurance Regulations define the
agent for physicians) and the Nova Scotia Department of terms for payments by the Minister of Health and Wellness to
Health and Wellness. Fee-for-service is still the most prevalent hospitals for insured hospital services.
method of payment for physician services; however, there has
been significant growth in the number of alternative payment In 2014–2015, there were 3,069 hospital beds in Nova Scotia
arrangements in place in Nova Scotia. (3.3 beds per 1,000 population). Department of Health and
Wellness direct expenditures for insured hospital services
operating costs were increased to $1,735,234,990.


FEDERAL TRANSFERS
In Nova Scotia, the Health Services and Insurance Act
acknowledges the federal contribution regarding the cost of
insured hospital services and insured health services provided
to provincial residents. The residents of Nova Scotia are aware
of ongoing federal contributions to Nova Scotia health care
through the Canada Health Transfer (CHT) as well as other
federal funds through press releases and media coverage.
The Government of Nova Scotia also recognized the federal

contribution under the CHT in various published documents,
including the following documents:
■■ Public Accounts 2013–2014 released July 24, 2014; and

■■ Budget Estimates and Supplementary Detail 2014–2015
released April 3, 2014.

REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
1. Number as of March 31st (#). 988,585 994,018 998,763 1,000,124 1,001,708

Public facilities 2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
2. Number (#). 35 35 35 35 35
3. Payments for insured health services ($).1 1,560,236,537 1,593,552,159 1,619,915,286 1,679,289,646 1,735,234,990

providing insured health services (#). 2 0 0 0 0 0

for insured health services ($). not applicable not applicable not applicable not applicable not applicable

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

10. Total number of claims, in-patient (#). not available not available not available not available not available
11. Total payments, in-patient ($). 788,368 2,176,921 1,104,701 1,242,889 777,019
12. Total number of claims, out-patient (#). not applicable not applicable not applicable not applicable not available
13. Total payments, out-patient ($). not applicable not applicable not applicable not applicable not available
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.


2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
14. Number of participating physicians (#). 2,434 2,473 2,507 2,581 2,580
16. Number of non-participating physicians (#). not applicable not applicable not applicable not applicable not applicable

methods ($). 661,968,168 681,963,292 694,184,053 712,629,560 730,417,814


2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 7,426,414 8,297,188 8,512,631 8,607,696 8,884,002

22. Total payments ($). 169,312 185,142 110,695 173,452 157,344

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
24. Number of services provided (#). 3 6,913 7,228 7,007 7,391 8,492
25. Total payments ($). 4 1,459,608 1,338,592 1,397,223 1,356,416 1,442,994
3. Total services includes block funded dentists.

4. Total payments does not include block funded dentists.

NEW BRUNSWICK
INTRODUCTION 1.2 Reporting Relationship

During 2014–2015, New Brunswick’s health system partners The Medicare—Insured Services Branch and the Medicare—
continued their efforts to ensure the health care system Eligibility and Claims Branch of the Department are mandated
remained effective, efficient and affordable. Through the work to administer the Medical Services Plan. The Minister reports
of all the health partners — Horizon Health Network, Vitalité to the Legislative Assembly through the Department’s annual
Health Network, FacilicorpNB, NB Health Council and the report and through regular legislative processes.
Department of Health — they collectively worked towards
The Regional Health Authorities Act establishes the regional
improving the system’s performance to better meet the needs
health authorities (RHAs) and sets forth the powers, duties,
of today and, tomorrow while continuing a commitment to the
and responsibilities of the same. The Minister is responsible
five fundamental principles under the Canada Health Act.
for the administration of the Act, provides direction to each
For information concerning any of the province’s health RHA, and may delegate additional powers, duties or functions
programs and services, please visit the New Brunswick to the RHAs.
Ministry of Health website at: www.gnb.ca/health

1.0 PUBLIC ADMINISTRATION Three groups have a mandate to audit the Medical Services Plan.
The Office of the Auditor General: In accordance with

1.1 Health Care Insurance Plan and the Auditor General Act, the Office of the Auditor General
Public Authority conducts the external audit of the accounts of the Province of
New Brunswick, which includes the financial records of the
In New Brunswick, the formal name for Medicare is the Department. The Auditor General also conducts management
Medical Services Plan. The Minister of Health (Minister) is reviews on programs as he or she sees fit.
responsible for operating and administering the plan by virtue
of the Medical Services Payment Act and its regulations. The Act The Office of the Comptroller: The Comptroller is the
and regulations set out who is eligible for Medicare coverage, the chief internal auditor for the Province of New Brunswick
rights of the patient, and the responsibilities of the Department and provides accounting, audit and consulting services in
of Health (the Department). This law establishes a Medicare accordance with responsibilities and authority set out in
plan, and defines which Medicare services are covered and the Financial Administration Act.
which are excluded. It also stipulates the type of agreements the
Monitoring and Compliance Team: This team is tasked with
Department may enter into with provinces and territories and
managing compliance with the Medical Payment Services Act
with the New Brunswick Medical Society. As well, it specifies
and regulations, as well as the Negotiated Fee Schedule.
the rights of a medical practitioner; how the amounts to be paid
for medical services will be determined; how assessment of
accounts for medical services may be made; and confidentiality
and privacy issues as they relate to the administration of the Act.

CHAPTER 3: NEW BRUNSWICK
2.0 COMPREHENSIVENESS A physician or the Department may request the addition

of a new service. All requests are considered by the New
Service Items Committee, which is jointly managed by the
New Brunswick Medical Society and the Department. The
2.1 Insured Hospital Services decision to add a new service is usually based on conformity to
Legislation providing for insured hospital services includes the the definition of “medically necessary” and whether the service
Hospital Services Act, section 9 of Regulation 84–167, and the is considered generally acceptable practice (not experimental)
Hospital Act. Under Regulation 84–167 of the Hospital Services within New Brunswick and/or Canada. Considerations under
Act, New Brunswick residents are entitled to the following the term “medically necessary” include services required for
insured hospital services: maintaining health, preventing disease and/or diagnosing or
treating an injury, illness or disability. No public consultation
Insured in-patient services include: accommodation and process is used.
meals; nursing; laboratory/diagnostic procedures; drugs; the
use of facilities (e.g., surgical, radiotherapy, physiotherapy); In 2014–2015 no new services were added to the list of
and services provided by professionals within the facility. insured services.
Insured out-patient services include: laboratory and

diagnostic procedures; mammography; and the hospital 2.3 Insured Surgical-Dental Services
component of available out-patient services for maintaining
health, preventing disease and helping diagnose or treat any Schedule 4 of Regulation 84–20 under the Medical Services
injury, illness or disability, excluding those related to the Payment Act identifies the insured surgical-dental services that
provision of drugs or third party diagnostic requests. can be provided by a qualified dental practitioner in a hospital,
providing the condition of the patient requires services to be
rendered in a hospital.
2.2 Insured Physician Services In addition, a general dental practitioner may be paid to assist
The Medical Services Payment Act and corresponding regulations another dentist for medically required services under some
provide for insured physician services. As of March 31, 2015 conditions. In addition to Schedule 4 of Regulation 84–20,
there were 1,631 participating physicians in New Brunswick. oral maxillofacial surgeons (OMS) have added access to
No physicians rendering health care services elected to opt out approximately 300 service codes in the Physician Manual
of the Medical Services Plan. When a physician opts out of and can admit or discharge patients and perform physical
Medicare, they must complete the specified Medicare claim examinations, including those performed in an out-patient
form and indicate the amount charged to the patient. The setting. OMSs may also see patients for consultation in
beneficiary then seeks reimbursement by certifying on the their office.
claim form that the services have been received and forwarding
As of March 31, 2015, there were just over 100 OMSs
the claim form to Medicare. The charges must not exceed the
and dentists registered in New Brunswick; in 2014–2015,
Medicare tariff. If the charges are in excess of the Medicare
18 provided services insured under the Medical Services Plan.
tariff, the practitioner must inform the beneficiary before
rendering the service that:
■■ they have opted out and charge fees above the Medicare tariff; 2.4 Uninsured Hospital, Physician and
■■ in accepting services under these conditions, the patient Surgical-Dental Services
waives all rights to Medicare reimbursement;
Uninsured hospital services include: take-home drugs; third-
■■ the patient is entitled to seek services from another prac party requests for diagnostic services; visits to administer drugs;
titioner who participates in the Medical Services Plan; and vaccines; sera or biological products; televisions and telephones;
■■ the physician must obtain a signed waiver from the patient preferred accommodation at the patient’s request; and hospital
on the specified form and forward the form to Medicare. services directly related to services listed under Schedule 2
of the Regulation under the Medical Services Payment Act.
The services which residents are entitled to under Medicare Services are not insured if provided to those entitled under
include: other statutes.
a) the medical portion of all medically required services The services listed in Schedule 2 of New Brunswick Regulation
rendered by medical practitioners; and 84–20 under the Medical Services Payment Act are specifically
excluded from the range of entitled medical services under
b) certain surgical-dental procedures when performed by
Medicare. They are as follows:
a physician or a dental surgeon in a hospital.

■■ elective plastic surgery or other services for cosmetic purposes; ■■ trans-sexual surgery;
■■ correction of inverted nipple; ■■ radiology services provided in the province by a private
■■ breast augmentation; radiology clinic;
■■ acupuncture;
■■ otoplasty for persons over the age of eighteen;
■■ complete medical examinations when performed for
■■ removal of minor skin lesions, except where the lesions are,
or are suspected to be, pre-cancerous; the purposes of periodic check-up and not for medically
necessary purposes;
■■ abortion, unless the abortion is performed in a hospital
■■ circumcision of a newborn;
facility approved by the jurisdiction in which the hospital
facility is located; ■■ reversal of vasectomies;
■■ surgical assistance for cataract surgery unless such assistance ■■ second and subsequent injections for impotence;
is required because of risk of procedural failure, other than ■■ reversal of tubal ligations;
risk inherent in the removal of the cataract itself, due to
existence of an illness or other complication; ■■ intrauterine insemination;
■■ medicines, drugs, materials, surgical supplies or prosthetic ■■ bariatric surgery unless the person has a body mass index of
devices; 40 or greater or of 35 or greater but less than 40, as well as
obesity-related comorbid conditions;
■■ advice or prescription renewal by telephone which is not
specifically provided for in the Schedule of Fees; ■■ venipuncture for purposes of taking blood when performed
as a stand-alone procedure in a facility that is not an
■■ examination of medical records or certificates at the request approved hospital facility.
of a third party, or other services required by hospital
regulations or medical by-laws; Dental services not specifically listed in Schedule 4 of the
■■ dental services provided by a medical practitioner or an oral Dental Schedule are not covered by the Plan. Those listed in
and maxillofacial surgeon; Schedule 2 are considered the only non-insured medical ser-
vices. There are no specific policies or guidelines, other than
■■ services that are generally accepted within New Brunswick the Act and regulations, to ensure that charges for uninsured
as experimental or that are provided as applied research; medical goods and services (e.g., fiberglass casts), provided in
■■ services that are provided in conjunction with, or in relation to, conjunction with an insured health service, do not compromise
the services referred to above; reasonable access to insured services.
■■ testimony in a court or before any other tribunal; The decision to de-insure physician or surgical-dental services
■■ immunization, examinations or certificates for purpose of is based on the conformity of the service to the definition of
travel, employment, emigration, insurance or at the request “medically necessary,” a review of medical service plans across
of any third party; the country, and the previous use of the particular service.
■■ services provided by medical practitioners or oral and maxil- Once a decision to de-insure is reached, the Medical Services
lofacial surgeons to members of their immediate family; Payment Act dictates that the government may not make any
changes to the Regulation until the advice and recommenda-
■■ psychoanalysis; tions of the New Brunswick Medical Society are received or
■■ electrocardiogram (E.C.G.) where not performed by a until the period within which the Society was requested by
specialist in internal medicine or paediatrics; the Minister to furnish advice and make recommendations
has expired. Subsequent to receiving their input and resolution
■■ laboratory procedures not included as part of an examination
of any issues, a regulatory change is completed. Physicians are
or consultation fee;
informed in writing following notification of approval. The
■■ refractions; public is usually informed through a media release. No public
■■ services provided within the province by medical consultation process is used.
practitioners, oral and maxillofacial surgeons or dental
In 2014–2015, no services were removed from the insured
practitioners for which the fee exceeds the amount payable
services list.
under regulation;
■■ the fitting and supplying of eye glasses or contact lenses;

3.0 UNIVERSALITY ■■ non-Canadians who are issued certain types of Canadian

authorization permits (e.g., a Student Authorization).
Persons who are discharged or released in New Brunswick from
3.1 Eligibility the Canadian Armed Forces, or a federal penitentiary, become
eligible for coverage on the date of their discharge or release.
Sections 3 and 4 of the Medical Services Payment Act and An application must be completed and signed, and have proof
Regulation 84–20 define eligibility for the health care of Canadian citizenship, proof of residency and the official
insurance plan in New Brunswick. date of release.
Residents are required to complete a Medicare application and

provide proof of Canadian citizenship, proof of residency, or a 3.2 Other Categories of Individuals
valid Canadian immigration document. A resident is defined
as a person lawfully entitled to be, or to remain, in Canada, Non-Canadians who may be issued an immigration permit
who makes his or her home and is ordinarily present in New that would not normally entitle them to Medicare coverage are
Brunswick, but does not include a tourist, transient, or visitor eligible provided that they are legally married to, living in a
to the province. common-law relationship with or are a dependent of an eligible
New Brunswick resident and possess a valid immigration
As of March 31, 2015, there were 750,691 persons registered permit. They are required to provide an updated immigration
in New Brunswick. document prior to the previous permit expiring.
All persons entering or returning to New Brunswick (excluding
children adopted from outside Canada) have a waiting period
before becoming eligible for Medicare coverage. Coverage 4.0 PORTABILITY
commences on the first day of the third month following the
month of arrival. Exceptions are as follows:
■■ Dependents of Canadian Armed Forces personnel or their
spouses moving from within Canada to New Brunswick are A person is eligible for New Brunswick Medicare coverage on
entitled to first day coverage under the program, provided the first day of the third month following the month permanent
they are deemed to have established permanent residency residency has been established. The three month waiting
in New Brunswick. period is legislated under New Brunswick’s Medical Services
Payment Act. Refer to section 3.1 for exceptions.
■■ Immigrants or Canadian residents moving or returning
to New Brunswick from outside of Canada are entitled
to first day coverage, provided they are deemed to have 4.2 Coverage During Temporary Absences
established permanent residency in the province. Proper
documentation is required (Immigration and Citizenship in Canada
documentation) and decisions on coverage and residency
The legislation that defines portability of health insurance
are reviewed on a case-by-case basis.
during temporary absences in Canada is the Medical Services
Residents who were not eligible for Medicare coverage during Payment Act, Regulation 84–20, sub-sections 3(4) and 3(5).
this reporting period included:
Medicare coverage may be extended upon request in the case
■■ regular members of the Canadian Armed Forces; of temporary absences to:
■■ inmates at federal institutions; ■■ students in full-time attendance at an educational institution

■■ temporary residents; outside New Brunswick;
■■ a family member who moves from another province to ■■ residents temporarily working in another jurisdiction; and
New Brunswick before other family members move; ■■ residents whose employment requires them to travel outside
■■ persons who have entered New Brunswick from another the province.
province to further their education and who are eligible
to receive coverage under the medical services plan of that
province; and

Students Residents temporarily employed outside Canada are granted

coverage for 182 days. This may be extended up to 12 months
Those in full-time attendance at a university or other approved within a three year period upon approval from the Director of
educational institution, who leave the province to further their Medicare Eligibility and Claims. Exceptions to this are Mobile
education in another province, will be granted coverage for and Contract workers.
a 12 month period that is renewable, provided the following
terms are met: Coverage for any absence over 212 days for vacation purposes
requires approval from the Director of Medicare Eligibility
■■ Medicare is contacted once every 12 months; and Claims. This approval can only be for up to 12 months in
■■ permanent residency is not established outside New Brunswick; duration and will only be granted once every three years.
and
New Brunswick residents exceeding the 12 month extension
■■ health coverage is not received elsewhere. have to reapply for New Brunswick Medicare upon their return
to the province. In this instance, cases are reviewed on a case by
Residents case basis. Depending on the circumstances, some cases may be
eligible for first day coverage while others who have been away
Residents temporarily employed in another province or territory, from the province slightly beyond the 12 month period may be
are granted coverage for up to 12 months provided the following given a grace period.
terms are met:
Insured residents who receive insured emergency services
■■ permanent residency is not established outside New Brunswick; out-of-country are eligible to be reimbursed $100 per day
and for in-patient stays and $50 per out-patient visit. The insured
■■ health insurance coverage is not received elsewhere.
resident is reimbursed for physician services associated with the
emergency treatment at New Brunswick rates. The difference
New Brunswick has formal agreements for reciprocal billing in rates is the patient’s responsibility.
arrangements of insured hospital services with all provinces
and territories. In addition, New Brunswick has reciprocal Mobile Workers
agreements with all provinces, except Quebec, for the provision
of insured physician services. Services provided by Quebec Mobile Workers are residents whose employment requires
physicians to New Brunswick residents are paid at Quebec rates them to travel outside the province (e.g., pilots). The following
provided the service delivered is insured in New Brunswick. guidelines must be met to receive Mobile Worker designation:
The majority of such claims are received directly from Quebec
physicians. Any claims submitted directly by a patient are reim- ■■ applications must be in writing;
bursed to the patient. ■■ documentation is required as proof of Mobile Worker status
(e.g., letter from employer or contract confirming that
frequent travel is necessary outside the province; a letter from
4.3 Coverage During Temporary Absences the resident detailing their permanent residence as New
Outside Canada Brunswick and the frequency of their return to the province;
a copy of their New Brunswick driver’s license; if working
The legislation that defines portability of health insurance outside Canada, a copy of resident’s immigration documents
during temporary absences outside Canada is the Medical that allow them to work outside the country); and
Services Payment Act, Regulation 84–20, subsections 3(4) ■■ the worker must return to New Brunswick during their
and 3(5). off-time.
Eligibility for temporarily absent New Brunswick residents is Mobile Worker status is assigned for a maximum of two years,
determined in accordance with the Medical Services Payment Act after which the resident must reapply and submit documentation
and regulations and the Interprovincial Agreement on Eligibility to confirm a continuation of Mobile Worker status.
and Portability.
The Interprovincial Agreement on Eligibility and Portability

is for within Canada and has no bearing on the individual
provinces handling of movement outside of Canada.

Contract Workers If the above requirements are met, it is mandatory to request

prior approval from Medicare in order to receive coverage.
Any New Brunswick resident accepting a contract out-of-country A physician, patient or family member may request prior
must supply the following information and documentation: approval to receive these services outside the country,
accompanied by supporting documentation from a Canadian
■■ a letter of request from the New Brunswick resident with specialist or specialists.
their signature, detailing their absence, Medicare number,
address, departure and return dates, destination, forwarding Out-of-country insured services that are not available in
address, and reason for absence; and Canada, are non-experimental, and receive prior approval
■■ a copy of a contractual agreement between employee and are paid in full. Often the amount payable is negotiated
employer indicating start and end dates of employment. with the provider by Europ Assistance — Global Corporate
Solutions on the province’s behalf.
Contract Worker status is assigned up to a maximum of two
years. Any further requests for contract worker status must be Heamodialysis is exempt from the out-of-country coverage
forwarded to the Director of Medicare Eligibility and Claims policy. Patients are required to obtain prior approval and
for approval on an individual basis. Medicare will reimburse the resident at a rate equivalent
to the inter-provincial rate of $472 per session.
Students Prior approval is also required to refer patients to psychiatric
hospitals and addiction centres outside the province because
Those in full-time attendance at a university or other approved they are excluded from the Interprovincial Reciprocal Billing
educational institution in another country will be granted Agreement. A request for prior approval must be received
coverage for a 12 month period that is renewable, provided they by Medicare from the Addiction Services or Mental Health
comply with the following: branches of the Department.
■■ proof of enrolment must be provided from the educational
institution on an annual basis;
■■ Medicare must be contacted once every 12 months;
5.0 ACCESSIBILITY
■■ permanent residency cannot be established outside
New Brunswick; and 5.1 Access to Insured Health Services
■■ health insurance coverage cannot be received elsewhere. New Brunswick’s health care system delivers equitable,
quality care to the public it serves. New Brunswick does not
charge user fees for insured health services as defined by the
4.4 Prior Approval Requirement Canada Health Act.
Medicare may cover out-of-country services that are not Access in a resident’s official language of choice is not a limiting
available in Canada on a pre-approval basis only. Residents factor, regardless of where a resident receives services in
may opt to seek non-emergency out-of-country services; the province.
however, they are responsible for assuming the total cost.
New Brunswick residents may be eligible for reimbursement

if they receive elective medical services outside the country,
5.2 Physician Compensation
provided the following requirements are met: Payments to physicians and dentists are governed under the
Medical Services Payment Act, Regulations 84–20, 93–143
■■ the required service or equivalent, or an alternate service
and 2002–53.
must not be available in Canada;
■■ the service must be rendered in a hospital listed in the The methods used to compensate physicians for providing
current edition of the American Hospital Association insured health services in New Brunswick are fee-for-service,
Guide to the Health Care Field (guide to United States salary and sessional, or alternate payment mechanisms that
hospitals, health care systems, networks, alliances, may include a blended system.
health organizations, agencies and providers);
■■ the service must be rendered by a medical doctor; and
■■ the service must be an accepted method of treatment
recognized by the medical community and be regarded as
scientifically proven in Canada. Experimental procedures
are not covered.

5.3 Payments to Hospitals Any requests for funding for new programs or services are sub-
mitted to the Deputy Minister of Health for approval. Funding
The legislative authorities governing payments to hospital for approved new programs or services is based on requirements
facilities in New Brunswick are the Hospital Act, which governs identified through discussions between Department of Health
the administration of hospitals, and the Hospital Services Act, and RHA staff. These amounts are added to the RHA funding
which governs the financing of hospitals. The Regional Health base once there is agreement on the funding requirements.
Authorities Act provides for the delivery and administration of
health services in defined geographic areas within the province.
The Department mainly distributes available funding to New

Brunswick’s regional health authorities (RHAs) through a FEDERAL TRANSFERS
Current Service Level approach. The funding base of the RHA
from the previous year is the starting point, to which approved New Brunswick recognizes the federal role regarding its
salary increases and a global inflator for non-wage items are contributions under the Canada Health Transfer in public
added. This applies to all clinical services provided by hos- documentation presented through legislative and administra-
pital facilities, as well as support services (e.g., administration, tive processes. Federal transfers are identified in the Main
food services, etc.). Funding for the Extra-Mural Program Estimates document and in the Public Accounts of New
(home care) is also part of the RHA base. Brunswick. Both documents are published annually by the
New Brunswick government.
Funding for FacilicorpNB, a shared services agency that man-
ages the information technology, materials management,
laundry and clinical engineering components of the hospital
facilities in New Brunswick, is also based on the Current
Service Level approach.

REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

2. Number (#). 57 56 59 60 60
3. Payments for insured health services ($). 1,616,340,008 1,721,356,342 1,736,939,230 1,771,731,561 1,876,686,329

providing insured health services (#).1 0 0 0 0 0

for insured health services ($).1 0 0 0 0 0

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

12. Total number of claims, out-patient (#). 1,805 1,285 1,080 1,004 882
1. There are no private for-profit facilities operating in New Brunswick.


2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
14. Number of participating physicians (#). 2 1,588 1,618 1,640 1,635 1,631

methods ($). 3 538,111,685 543,148,047 581,432,080 554,684,438 577,131,145


2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 11,965,539 13,221,951 15,089,061 22,127,528 18,284,577

22. Total payments ($). 568,937 635,020 397,912 315,078 246,305

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
23. Number of participating dentists (#). 4 14 23 20 21 18
25. Total payments ($). 367,905 712,367 663,654 718,088 618,627
2. These are the number of physicians with an active physician status on March 31st of each year.
3. The total payment for all payment methods is a preliminary figure and includes budgeted amounts for alternate funding plans. Fee-for-service is for automated
fee-for-service only.
4. These are the number of dentists and oral maxillofacial surgeons (OMS) participating in New Brunswick’s Medical Services Plan during each fiscal year.
Out of the 100+ dentists and OMSs registered, these billed the Medical Services Plan.

QUEBEC
1.0 PUBLIC ADMINISTRATION Out-patient services include the following: Clinical services for
psychiatric care; electroshock, insulin and behaviour therapies;
emergency care; minor surgery (day surgery); radiotherapy;
diagnostic services; physiotherapy; occupational therapy;
1.1 Health Care Insurance Plan and inhalation therapy, audiology, speech therapy and orthoptic
Public Authority services; and other services or examinations required under
Quebec legislation.
The Quebec Hospital Insurance Plan is administered by the
Ministère de la Santé et des Services Sociaux (MSSS) [the Other insured services include the following: Mechanical,
Quebec Ministry of Health and Social Services]. hormonal or chemical contraception services; surgical
sterilization services (including tubal ligation or vasectomy);
Quebec’s health and drug insurance plans are administered reanastomosis of the fallopian tubes or vas deferens; and
by the Régie de l’assurance maladie du Québec (the Régie), extraction of a tooth or root when the patient’s health status
a public body established by the provincial government that makes hospital services necessary.
reports to the Minister of Health and Social Services.
The MSSS administers an ambulance transportation program
that is free of charge to persons aged 65 and older.
1.2 Reporting Relationship
In addition to basic insured health services, the Régie also
The Public Administration Act (R.S.Q., c. A-6.01) sets forth covers optometric services for people who are under age 18 and
government criteria for preparing reports on the planning and 65 and over, and for last-resort financial assistance recipients;
performance of public authorities, including the MSSS and dental care for children age 10 and under and last-resort
the Régie. financial assistance recipients; and acrylic dental prostheses
for last-resort financial assistance recipients.
1.3 Audit of Accounts It also covers, for Quebec residents, as defined in the Health
Insurance Act (R.S.Q. c. A 29) who meet the eligibility
The Quebec Hospital Insurance Plan and the Quebec health criteria for each program, prostheses, orthotics, orthopedic
and drug insurance plans are administered by the public appliances, walking and posture aids; hearing aids and assistive
authorities on a non-profit basis. All books and accounts listening devices; visual aids; external breast prostheses; ocular
are audited by the auditor general of the province. prostheses; permanent ostomy appliances and compression
clothing for people with lymphedema.
2.0 COMPREHENSIVENESS With regard to drug insurance, since January 1, 1997, the Régie
has covered, in addition to recipients of last-resort financial
assistance and persons aged 65 and over, Quebec residents who
2.1 Insured Hospital Services otherwise would not have access to a private drug insurance plan.
In 2014–2015, the drug insurance plan covered 3.5 million
Insured in-patient services include the following: Standard insured persons.
ward accommodation and meals; necessary nursing services;
routine surgical supplies; diagnostic services; use of operating
rooms, delivery rooms and anaesthetic facilities; medication; 2.2 Insured Physician Services
prosthetic and orthotic devices that can be integrated with
the human body; biological products and related preparations; Services insured under this plan include medical and surgical
use of radiotherapy and physiotherapy facilities; and services services that are provided by physicians participating in the
delivered by hospital staff. plan and are medically necessary.

CHAPTER 3: QUEBEC
Family planning services set forth by legislation and provided ultrasonography, unless this service is delivered in a hospital
by a physician are insured, as are assisted reproduction services centre or, for obstetrical purposes, in a local community
set forth by regulation. service centre (CLSC) recognized for that purpose; optical
tomography of the eyeball and confocal scanning laser
ophthalmoscopy of the optic nerve, unless these services are
2.3 Insured Surgical-Dental Services delivered in a facility maintained by an institution that operates
a hospital or are delivered in association with the delivery,
Services insured under this plan include maxillo-facial by intravitreal injection, of an antiangiogenic drug for the
surgery performed by dental surgeons and specialists in oral treatment of age-related macular degeneration; any radiological
and maxillo-facial surgery, in a prescribed hospital centre or or anaesthetic service provided by a physician if required for
university institution. the provision of an uninsured service, with the exception of
a dental service provided in a hospital centre or, in the case
of radiology, if required by a person other than a physician or
2.4 Uninsured Hospital, Physician and dentist; any sex-reassignment surgery, unless it is provided on
Surgical-Dental Services the recommendation of a physician specializing in psychiatry
and is provided in a hospital centre recognized for this purpose;
Uninsured hospital services include plastic surgery for purely and any services that are not related to pathology and that are
cosmetic purposes, a private or semi-private room at the delivered by a physician to a patient between 18 and 65 years
patient’s request, televisions, telephones, drugs and biological of age, unless that individual is the holder of a claim booklet
products ordered after discharge from hospital, and services for colour blindness or a refractive error, in order to provide
for which the patient is covered under the Act respecting or renew a prescription for eyeglasses or contact lenses.
industrial accidents and occupational diseases or other federal
or provincial legislation.
The following services, among others, are not insured:

3.0 UNIVERSALITY
any examination or service not related to a process of curing
or preventing illness; psychoanalysis of any kind, unless 3.1 Eligibility
such service is delivered in a facility maintained by an
institution authorized for such purpose by the Minister of Registration with the hospital insurance plan is not required.
Health and Social Services; any service provided solely for Registration with the Régie de l’assurance maladie du
aesthetic purposes; any refractive surgery, except where there Québec is sufficient to establish an individual’s eligibility.
is documented failure in respect of corrective lenses and Any individual residing or staying in Quebec as defined in
contact lenses for astigmatism of more than 3.00 diopters the Health Insurance Act must be registered with the Régie de
or anisometropia of more than 5.00 diopters measured l’assurance maladie du Québec to be eligible for hospital services.
from the cornea; any consultation by telecommunication or
by correspondence; any service delivered by a professional
to his or her spouse or children; any examination, expert 3.2 Other Categories of Individuals
appraisal, testimony, certificate or other formality required
for legal purposes or by a person other than the one who Inmates in federal penitentiaries are not covered by the plan.
has received an insured service, except in certain cases; any
visit made for the sole purpose of obtaining the renewal of a Certain categories of residents, notably permanent residents
prescription; any examination, vaccination, immunization or under the Immigration Act and persons returning to live in
injection where the service is provided to a group or for certain Canada, become eligible under the plan following a waiting
purposes; any service delivered by a professional on the basis period of up to three months. Persons from another country
of an agreement or contract with an employer, association receiving last-resort financial assistance benefits are eligible
or body; any adjustment of eyeglasses or contact lenses; any upon registration. Canadian Forces personnel and their family
surgical extraction of a tooth or dental fragment performed members posted to Quebec from another Canadian province or
by a physician, unless such a service is provided in a hospital territory who have a status permitting them to settle there are
centre in certain cases; all acupuncture procedures; injection eligible on the date of their arrival. Members of the Canadian
of sclerosing substances and the examination performed at Forces who have not acquired Quebec resident status, and
that time; mammography used for detection purposes, unless inmates of federal penitentiaries become eligible the day they
this service is required by medical prescription in a place are discharged or released. Immediate coverage is provided for
designated by the Minister to a recipient 35 years of age or certain seasonal workers, repatriated Canadians, persons from
older, provided that the person has not been so examined outside Canada who are living in Quebec under an official
for one year; thermography, tomodensitometry, magnetic bursary or internship program of the Ministère de l’Éducation
resonance imaging and use of radionuclides in vivo in humans, (the Quebec Department of Education), persons from outside
unless these services are delivered in a hospital centre; Canada who are eligible under an agreement or accord reached

CHAPTER 3: QUEBEC
with a country or an international organization, and refugees. Centre de santé de Témiscaming (Temiscaming Health Centre)
Persons from outside Canada who have work permits and and the North Bay Regional Health Centre.
are living in Quebec for the purpose of holding an office or
employment for a period of more than six months become Costs of hospital services provided in another province or
eligible for the plan following a waiting period. territory of Canada are paid in accordance with the terms
and conditions of the Hospital Reciprocal Billing Agreement
regarding hospital insurance agreed to by the provinces
4.0 PORTABILITY and territories of Canada. These costs are paid either at the
established per diem for hospitalization in a standard ward or
in intensive care proposed by the host province and approved
4.1 Minimum Waiting Period by all the provinces and territories or, in cases of outpatient
services or expensive procedures, at the approved interprovincial
Persons settling in Quebec after moving from another province rates. Insured persons who leave Quebec to settle in another
of Canada are entitled to coverage under the Quebec Health province or territory of Canada are covered for up to three
Insurance Plan when they cease to be entitled to benefits from months after leaving the province.
their province of origin, provided they register with the Régie.

4.2 Coverage During Temporary Absences Outside Canada
in Canada
Students, unpaid trainees, Quebec government officials posted
If living outside Quebec in another province or territory abroad and employees of non-profit organizations working in
for 183 days or more, and provided they notify the Régie of international aid or co-operation programs recognized by the
this, students and full-time unpaid trainees may retain their Minister of Health and Social Services must contact the Régie
status as residents of Quebec: students for a maximum of four to determine their eligibility. If the Régie grants them special
consecutive calendar years, and full-time unpaid trainees for status, they receive full reimbursement for hospital costs in
a maximum of two consecutive calendar years. case of emergency or sudden illness, and are reimbursed up
to 75 percent in other cases.
This is also the case for persons living in another province or
territory who are temporarily employed or working on contract As of September 1, 1996, hospital services provided outside
there. Their resident status can be maintained for no more than Quebec in case of emergency or sudden illness for persons
two consecutive calendar years. employed directly by a company or corporate body with
its headquarters or a place of business in Quebec to which
Persons directly employed or working on contract outside they report directly, or for persons employed by the federal
Quebec for a company or corporate body with its headquarters government and posted outside Quebec, are reimbursed in full
or a place of business in Quebec, to which they report directly, by the Régie, and reimbursed up to 75 percent in other cases.
or persons employed by the federal government and posted
outside Quebec also retain their status as a resident of the For residents who receive insured services in a hospital outside
province. The same is true of persons who remain outside the Canada, the Régie reimburses the cost of such services in case of
province for 183 days or more, but less than 12 months within emergency or sudden illness to a maximum of C$100 per day if
a calendar year, provided such an absence occurs only once the patient was hospitalized (including in the case of day surgery)
every seven years. or to a maximum of C$50 per day for outpatient services.
However, hemodialysis treatments are covered to a maximum
The costs of insured services provided by health professionals of C$220 per treatment, including medications, whether the
in another province or territory of Canada are reimbursed the patient is hospitalized or not. In these cases, the Régie covers
amount actually paid or the rate that would have been paid the associated professional services at the lowest cost, either the
by the Régie for such services in Quebec, whichever is less. amount actually paid or what would have been paid by the Régie
However, Quebec has negotiated a permanent arrangement for the same services in Quebec. The services must be delivered
with Ontario to pay Ottawa doctors at the Ontario fee rate in a hospital, or hospital centre, recognized and accredited by the
for specialized services that are not available in the Outaouais appropriate authorities. No reimbursements are made for nursing
region. This agreement came into effect on November 1, 1989. homes, spas or similar establishments, or for any services that are
The Régie covers the amount it would have paid for the same experimental in nature.
services in Quebec, and the Agence de la santé et des services
sociaux de l’Outaouais (Outaouais health and social services Costs for insured services provided by physicians, dentists,
agency) pays the difference between the cost invoiced by maxillo-facial surgeons and optometrists are reimbursed at
Ontario and the amount initially reimbursed by the Régie. A the rate that would have been paid by the Régie to a health
similar agreement was signed in December 1991 between the professional recognized in Quebec, up to the amount of the
expenses actually incurred. When they are delivered abroad,

CHAPTER 3: QUEBEC
all professional services insured by the Quebec Health general and specialized hospital services, and social services. To
Insurance Plan are reimbursed at the Quebec rate, usually do so, they must enter into service agreements with other health
in Canadian funds. sector organizations. The linking of services within a territory
forms the local services network. Thus, the aim of integrated
An insured person who moves permanently from Quebec to local health and social services networks is to make all the
another country ceases to be a recipient on the day of departure. stakeholders in a given territory collectively responsible for
the health and well-being of the people in that territory.
Residents of Quebec who are working or studying abroad are
covered by that country’s plan when the stay falls under a social Family medicine groups (FMGs) were established in
security agreement reached between the Minister of Health 2003–2004. A FMG is a group of doctors working as a
and Social Services and the country in question. team and in close collaboration with nurses and other CSSS
professionals from CSSSs to provide services ranging from
disease prevention, health assessment and patient monitoring,
4.4 Prior Approval Requirement as well as diagnosis and treatment of acute and chronic
problems. Their services include medical consultations with
To receive full reimbursement for hospital services elsewhere
and without an appointment, seven days a week, and an
in Canada or in another country, that are not covered under
adapted response to people whose health status requires special
agreements, a written request signed by two physicians with
arrangements for access to services. As of March 31, 2015,
expertise in the field of pathology of the person on whose
there were 262 accredited FMGs and 53 network-clinics in
behalf the request is made must first be sent to the Régie. The
Quebec. Forty-five of the network-clinics are also FMGs.
request must describe the specialized services required by the
insured person, must attest to the unavailability of said services
in Quebec or Canada, and must contain information about
the treating physician and the address of the hospital where
5.2 Physician Compensation
the services would be provided. Following an evaluation of Physicians are remunerated in accordance with the negotiated
the request by the Régie, authorization to receive the services fee schedule. The Minister may enter into an agreement with
is either given or denied. No authorization will be given if the the organizations representing any class of health professional.
medical service in question is available in Quebec or if it is This agreement may prescribe a different rate of compensation
an experimental service. for medical services in a territory where the number of
professionals is considered insufficient.
5.0 ACCESSIBILITY While the majority of physicians practise within the provincial
plan, Quebec allows two other options: professionals who
withdraw from the plan and practise outside the plan, but
5.1 Access to Insured Health Services agree to be remunerated according to the provincial fee
schedule; and non-participating professionals who practise
Everyone has the right to receive adequate health care services outside the plan, with no reimbursement from the Régie
without any kind of discrimination. There is no extra-billing going to either them or their patients.
by Quebec physicians.
According to the most recent data available, in 2014–2015,
On March 31, 2014, Quebec had 141 facilities operating as the Régie paid an estimated $6.8 billion for professional
hospital centres for a clientele suffering from acute, general and services provided to Quebec residents. Professional services
specialized or psychiatric illnesses. On that date, 21,462 beds (including reimbursements to insured persons and payments
were allotted to these facilities. In these centres, according to the to professionals) received outside Quebec were estimated
most recent available data, from April 1, 2013, to March 31, 2014, at $41.4 million.
Quebec hospital institutions had 784,596 admissions, which
accounted for 6,691,464 patient days. In the same period, there
were 388,115 registrations for day surgeries. 5.3 Payments to Hospitals
Since 2003, the Quebec health care system has been based The Minister of Health and Social Services funds hospitals
on local services networks covering the entire province. through payments directly related to the cost of the insured
At the core of each of these local networks are the Health and services provided.
Social Services Centres (CSSS). The centres are the result of
the merger of public institutions whose mission was to provide The payments made in 2014–2015 to institutions operating as
local community service centre (CLSC) services, residential hospital centres for insured health services provided to residents
and long-term care services (CHSLD) and, in most cases, of Quebec totalled nearly $11.6 billion. Payments to hospital
neighbourhood hospital services. CSSSs must also provide the centres in other provinces or outside Canada for hospital
people in their territory with access to other medical services, services totalled approximately $217.97 million.

ONTARIO
INTRODUCTION 1.2 Reporting Relationship

Ontario has one of the largest and most complex publicly- The Health Insurance Act stipulates that the Minister of Health
funded health care systems in the world. Administered by and Long-Term Care is responsible for the administration and
the province’s Ministry of Health and Long-Term Care operation of OHIP, and is Ontario’s public authority for the
(MOHLTC), Ontario’s health care system was supported by purposes of the Canada Health Act.
over $50.0 billion (including capital) in spending for 2014–2015.
The Local Health System Integration Act, 2006 (LHSIA) requires
each LHIN to prepare an annual report on its affairs and oper-
1.0 PUBLIC ADMINISTRATION ations for the previous fiscal year. The Government of Ontario’s
Agency Establishment and Accountability Directive requires
that every Ontario operational service agency (including
LHINs) prepare an annual report. The Minister is required
1.1 Health Care Insurance Plan and to table the reports in the Legislative Assembly of Ontario.
Public Authority
MOHLTC has a performance agreement with each LHIN that
includes obligations, measures and targets for the networks.
Ontario Health Care and Health Care Planning The agreements also include the funding allocations by sector,
The Ontario Health Insurance Plan (OHIP) is administered for example, long-term care homes and hospitals. LHSIA
on a non-profit basis by the Ministry of Health and Long- provides the LHINs with the authority to fund defined health
Term Care (MOHLTC). OHIP was established in 1972 and service providers and to enter into service accountability
is continued under the Health Insurance Act, Revised Statutes agreements with health service providers.
of Ontario, 1990, c. H-6, to provide insurance in respect of
the cost of insured services provided to Ontario residents
(as defined in the Health Insurance Act) in hospitals and health 1.3 Audit of Accounts
facilities, and by physicians and other health care practitioners.
Every year the Auditor General of Ontario reports on the
The MOHLTC provides services to the public through results of his examination of government resources and admin-
programs such as health insurance, drug benefits, assistive istration. The Auditor General’s report is tabled by the Speaker
devices, forensic mental health and supportive housing, of the Legislative Assembly, usually in the fall, at which time
long‑term care, home care, community and public health, it becomes available to the public. Audit reports on select areas
and health promotion and disease prevention. It also regulates of the MOHLTC chosen for review by the Auditor General
hospitals and nursing homes, operates medical laboratories, are included within this annual report, the last of which was
and coordinates emergency health services. released on December 9, 2014.
Local Health Integration Networks (LHINs) were established MOHLTC’s accounts and transactions are published annu-
under the Local Health System Integration Act, 2006 (LHSIA) to ally in the Public Accounts of Ontario. The 2014–2015
help improve Ontarians’ health through better access to high- Public Accounts of Ontario were tabled and released on
quality health services, coordinated health care, and effective September 28, 2015.
and efficient management of the health system at the local level.
Since April 1, 2007, the LHINs have had responsibility for
funding, planning and integrating health care services at the
local level. This includes services delivered by hospitals, com-
munity care access centres, long-term care homes, community
health centres, community support services, and mental health
and addictions agencies.

CHAPTER 3: ONTARIO
2.0 COMPREHENSIVENESS surgical and diagnostic services, including primary health

care services. Services are provided in a variety of settings,
including: private physician offices, community health centres,
hospitals, mental health facilities, licensed independent health
2.1 Insured Hospital Services facilities, and long-term care homes.
Insured in-patient and out-patient hospital services in
In general terms, insured physician services include: diagnosis
Ontario are prescribed under the Health Insurance Act, and
and treatment of medical disabilities and conditions; medical
Regulation 552 under the Act.
examinations and tests; surgical procedures; maternity care;
Insured in-patient hospital services include medically required: anaesthesia; radiology and laboratory services in approved
use of operating rooms, obstetrical delivery rooms and facilities; and immunizations, injections and tests.
anaesthetic facilities; necessary nursing services; laboratory,
Physicians must be registered to practice medicine in Ontario
radiological and other diagnostic procedures together with
by the College of Physicians and Surgeons of Ontario, and be
the necessary interpretations for the purpose of maintaining
located in Ontario when rendering the service.
health, preventing disease and assisting in the diagnosis and
treatment of any injury, illness or disability; drugs, biologicals During 2014–2015, most physicians submitted claims for all
and related preparations; and accommodation and meals at the insured services rendered to insured persons directly to OHIP,
standard ward level. and a limited number billed the insured person. Physicians who
do not bill OHIP directly are commonly referred to as having
Insured out-patient services include medically required: labo-
opted out of the Plan. When a physician has opted out of the
ratory, radiological and other diagnostic procedures; use of
Plan the physician bills the patient not exceeding the amount
radiotherapy, occupational therapy, physiotherapy and speech
payable for the service under the Schedule of Benefits (this was
therapy facilities, where available; use of diet counselling
permitted on a grandparented basis following proclamation
services; use of the operating room and anaesthetic facilities;
of the Commitment to the Future of Medicare Act in 2004).
surgical supplies; necessary nursing service; supply of drugs,
The patient then recoups that amount from the Plan.
biologicals, and related preparations (subject to some excep-
tions); certain other specified services such as the provision There were approximately 29,380 physicians who submitted
of equipment, radiotherapy and occupational medication to claims to OHIP in 2014–2015. This figure includes physicians
haemophiliac patients for use at home; and certain specified submitting both fee-for-service claims and physicians included
home-administered drugs. in an alternative payment plan who submitted tracking or
shadow-billed claims. In 2014–2015, there were 24 opted-out
Hospital services are not specifically listed in Regulation 552
physicians in Ontario.
in the Health Insurance Act, rather, the Regulation lists broad
categories of services. This permits the Regulation to cover new The Schedule of Benefits — Physician Services is regularly
medical and technological advances as they become accepted reviewed and revised to reflect current medical practice and
standards of practice. new technologies. New services may be added, existing services
revised, or obsolete services removed through regulatory
Adding a new broad category of hospital services to the list of
amendment. This process involves consultation with the
insured services covered by the Ontario Health Insurance Plan
Ontario Medical Association.
(OHIP) requires a regulatory change. Regulatory changes are
approved by Cabinet and generally there is a public consultation In 2014–2015, in order to achieve savings, there were changes
process by way of Ontario’s Regulatory Registry. made to the Schedule of Benefits — Physician Services.
These changes were effective February 1, 2015.
No regulation changes to add hospital services were completed
in fiscal year 2014–2015.
2.3 Insured Surgical-Dental Services
2.2 Insured Physician Services In accordance with the Canada Health Act, certain surgical-
dental services are prescribed as insured services under
Insured physician services are prescribed under the
Regulation 552 in the Health Insurance Act and listed in
Health Insurance Act and regulations under the Act.
the Schedule of Benefits — Dental Services. The Health
Under Regulation 552 to the Health Insurance Act, a ser- Insurance Act authorizes OHIP to pay for a limited number of
vice provided by a physician in Ontario is an insured service procedures when the procedure is medically necessary, and it
if it is medically necessary; referred to in the Schedule of is medically necessary that the insured services be performed
Benefits — Physician Services; and rendered in such circum- in a public hospital graded under the Public Hospitals Act
stances or under such conditions as specified in the Schedule as Group A, B, C or D, by a dental surgeon who has been
of Benefits — Physician Services. Physicians provide medical, appointed to the dental staff of the public hospital.

CHAPTER 3: ONTARIO
Generally, insured dental services include: oral and maxillo-facial

surgery that normally would be required to be performed in a
3.0 UNIVERSALITY
hospital; root resection and apical curettage procedures when
performed in association with other insured dental procedures;
and dental extractions when performed in a hospital for the
3.1 Eligibility
safety of high risk patients and if prior approval is obtained from Section 11 of the Health Insurance Act specifies that every
the Ministry of Health and Long-Term Care (MOHLTC). person who is a resident of Ontario is entitled to become an
insured person under the Ontario Health Insurance Plan
With respect to insured surgical-dental services, MOHLTC
(OHIP) upon application. In order to be considered an Ontario
negotiates changes to the Schedule of Benefits — Dental
resident, Regulation 552 under the Health Insurance Act, with a
Services with the Ontario Dental Association. The MOHLTC
few exceptions that are noted in the Regulation, requires that
and the Ontario Dental Association agreed on a multi-year
a person must:
funding agreement for dental services, which became effective
on April 1, 2002. The existing Schedule of Benefits — Dental ■■ hold Canadian citizenship or an immigration status as
Services remains in effect and no new services were added to prescribed in Regulation 552;
the Schedule during the 2014–2015 fiscal year.
■■ make his or her primary place of residence in Ontario;
■■ subject to some limited exceptions, be physically present in
2.4 Uninsured Hospital, Physician and Ontario for at least 153 days in any 12-month period; and
Surgical-Dental Services ■■ for most new and returning residents, be physically present
in Ontario for 153 of the first 183 days following the date
Uninsured hospital services include but are not limited to: residence is established in Ontario, for example, a person
private or semi-private accommodation unless prescribed by a cannot be away from the province for more than 30 days
physician, oral-maxillofacial surgeon or midwife; telephones in the first six months of residency.
and televisions; charges for certain private-duty nursing; and
provision of medications for patients to take home from hos- Individuals who are not eligible for OHIP coverage are those
pital, with prescribed exceptions. who do not meet the definition of a resident, such as tourists,
transients, visitors to the province and those who do not hold
Section 24 of Regulation 552 details some specified physician immigration or other similar status. Services that a person
and supporting services that are not insured services. is entitled to receive under federal legislation are not insured
services, for example those provided to federal penitentiary
Uninsured physician services include: services that are not
inmates and Canadian Forces members. Services that a person
medically necessary; services not listed in the Schedule of
is entitled to receive under the Workplace Safety and Insurance Act
Benefits — Physician Services; and services that are excluded
are not insured services in Ontario.
from insured services under Section 24 of Regulation 552.
When it is determined that a person is not eligible, or is no
Dental services provided in dentists’ offices are not insured
longer eligible, for OHIP coverage, a request may be made to
and payment is the responsibility of the individual patient.
the Ministry of Health and Long-Term Care (MOHLTC) to
Dental services not specifically listed in the Dental Schedule
review the decision. Anyone may request that the MOHLTC
are also not insured including such services as dental
review the denial of their OHIP eligibility by making a request
implants, prosthetic restorations (fixed bridges and den-
in writing to the OHIP Eligibility Review Committee. Those
tures) for the replacement of teeth, orthodontic treatment,
who are not satisfied with the decision regarding their OHIP
fillings and crowns.
eligibility may request an appeal of their case by the Health
Complaints regarding charges for services, such as block fees or Services Appeal and Review Board.
enhanced medical goods or services, are investigated under the
MOHLTC is the sole payer for OHIP insured physician, hos-
Commitment to the Future of Medicare Act (CFMA) Program.
pital and hospital surgical-dental services. An eligible Ontario
Investigations are opened to determine whether any patient was
resident may not obtain any benefits from another insurance
charged for an insured service; this would include whether a
plan for the cost of any insured service that is covered by OHIP
block fee included charges for insured service, or if a charge for
(with the exception of during the OHIP waiting period).
an enhanced service was in fact for an uninsured service. If it
is found that a patient was charged for an insured service, the Persons who were previously ineligible for OHIP coverage
MOHLTC ensures that patients are reimbursed and providers but whose status and/or residency situation has changed may
are educated on the prohibitions in the CFMA. be eligible upon application, subject to the requirements of
Regulation 552.

CHAPTER 3: ONTARIO
3.2 Other Categories of Individuals A foreign worker is eligible for OHIP if the individual has been
issued a Work Permit or other document by CIC that permits
MOHLTC provides health insurance coverage to a limited the person to work in Canada, and if the person also has a
number of specified categories of residents of Ontario, other formal agreement in place to work full-time for an employer in
than Canadian citizens and permanent residents or landed Ontario. The work permit or other document issued by CIC,
immigrants. or a letter provided by the employer, must set out the employer’s
name, state the person’s occupation with the employer, and state
These residents are required to provide acceptable documentation that the person will be working for the employer for no less
to support their residence in Ontario and their identity in the than six consecutive months.
same manner as Canadian citizens and permanent resident or
landed immigrant applicants. A spouse and/or dependant (under 22 years of age; or 22 years of
age or older if dependent due to a mental or physical disability)
The individuals listed below who are residents in Ontario of an eligible foreign member of the clergy or an eligible foreign
may be eligible for OHIP coverage in accordance with worker is also eligible for OHIP coverage as long as the spouse
Regulation 552 of the Health Insurance Act. Individuals are or dependant is legally entitled to stay in Canada.
required to apply in person to ServiceOntario, which has the
government-wide mandate for the delivery of front-facing Live-in Caregivers: Eligible live-in caregivers are persons who
services to the residents of Ontario, including the issuance hold a valid Work Permit under the Live-in Caregiver Program
of the Ontario Photo Health Card. (LCP) administered by the Government of Canada. The Work
Permit for LCP workers does not have to list the three specific
Applicants for Permanent Residence: These are persons who employment conditions required for all other foreign workers.
have submitted an application for Permanent Resident status
to Citizenship and Immigration Canada (CIC) and CIC has Applicants for Canadian Citizenship: These individuals
confirmed that the person meets the eligibility requirements are eligible for OHIP coverage if they have submitted an
to apply for permanent residence in Canada and that the application for Canadian citizenship under section 5.1 of the
application has not yet been denied. federal Citizenship Act, even if the application has not yet been
approved, provided that CIC has confirmed that the person
Protected Persons: These are persons who are determined to be meets the eligibility requirements to apply for citizenship under
Protected Persons under the terms of the federal Immigration that section and the application has not yet been denied.
and Refugee Protection Act. Members of this group are provided
with immediate OHIP coverage. Children Born Out-of-Country: A child born to an OHIP-
eligible woman who was transferred from Ontario to receive
Holders of Temporary Resident Permits: A Temporary insured health services that were pre-approved for payment
Resident Permit is issued to an individual by CIC when there by OHIP is eligible for immediate OHIP coverage provided
are compelling reasons to admit an individual into Canada who that the mother was pregnant at the time of departure
would otherwise be inadmissible under the federal Immigration from Ontario.
and Refugee Protection Act. Each Temporary Resident Permit
has a case type or numerical designation on the permit that Seasonal Agricultural Farm Workers are persons who have
indicates the circumstances allowing the individual entry into a Work Permit issued under the Seasonal Agricultural Worker
Canada. Individuals who hold a permit with a case type of Program administered by the Government of Canada. Due to
86, 87, 88, 89, 90, 91, 92, 93, 94, 95 or 80 (if for adoption) are the special nature of their employment, migrant farm workers
eligible for OHIP coverage. Individuals who hold a permit with do not have to meet any other residency requirement and are
a case type of 80 (except for adoption), 81, 84, 85 and 96 are not provided with immediate OHIP coverage.
eligible for OHIP coverage.
Clergy, Foreign Workers and their Accompanying Family 3.3 Premiums

Members: An eligible foreign clergy is a person who is
sponsored by a religious organization or denomination if the No premiums are required to obtain OHIP coverage. There
member has finalized an agreement to minister to a religious is an Ontario Health Premium that is collected through the
congregation or group in Ontario for at least six months, provincial income tax system but it is not connected to OHIP
as long as the member is legally entitled to stay in Canada. registration or eligibility in any way. Responsibility for the
administration of the Ontario Health Premium lies with the
Ontario Ministry of Finance.

CHAPTER 3: ONTARIO
4.0 PORTABILITY Insured students who are temporarily absent from Ontario, but
remain within Canada, may be eligible for continuous health
insurance coverage for the duration of their full-time studies,
provided they do not establish permanent residency elsewhere
4.1 Minimum Waiting Period during this period. To ensure that they maintain continuous
In accordance with section 5 of Regulation 552 under the OHIP eligibility, a student should provide the Ministry of
Health Insurance Act, individuals who move to Ontario are Health and Long-Term Care (MOHLTC) with documentation
typically entitled to Ontario Health Insurance Plan (OHIP) or information from their educational institution confirming
coverage three months after establishing residency in the registration as a full-time student. Insured family members
province unless listed as an exception in sections 6, 6.1, (spouses and dependants) of students who are studying in
6.2, or 6.3 of Regulation 552, or sub section 11(2.1) of the another province or territory are also eligible for continuous
Health Insurance Act. OHIP eligibility while accompanying students for the duration
of their studies.
Assessment of whether or not an individual is subject to the
waiting period occurs at the time of their application for OHIP In accordance with Regulation 552 of the Health Insurance Act,
coverage. Examples of those who are exempt from the three most insured residents who want to travel, work or study
month waiting period include newborn babies, eligible military outside Ontario, but within Canada, and maintain OHIP
family members, and insured residents from another province coverage, must have resided in Ontario for at least 153 days
or territory who move to Ontario and immediately become in the last 12-month period immediately prior to departure
residents of an approved long-term care home in Ontario. from Ontario.
In accordance with Regulation 552 under the Health Insurance Act Ontario participates in Reciprocal Hospital Billing Agreements
and as provided for in the Interprovincial Agreement on with all other provinces and territories for insured in-patient
Eligibility and Portability, persons who permanently move to and out-patient hospital services. Rates are set and approved
Ontario from another Canadian province or territory where they annually by the Interprovincial Health Insurance Agreements
are insured will typically be eligible for OHIP coverage after the Coordinating Committee. Payment for in-patient services is at
last day of the second full month following the date residency is the hospital’s approved in-patient per diem rate. Payment for
established, in other words, an interprovincial waiting period. out-patient services is at the standard approved out-patient rate.
Ontario pays the standard out-patient charges set out by the

Interprovincial Health Insurance Agreements Coordinating
4.2 Coverage During Temporary Absences Committee. Ontario is also party to the Physicians’ Reciprocal
in Canada Billing Agreements with all other provinces and territories,
except Quebec (which has not signed a reciprocal physician
Insured out-of-province services are prescribed under sections 28, agreement with any other province or territory). Ontario resi-
28.0.1, and 29 of Regulation 552 of the Health Insurance Act. dents who may be required to pay for insured physician services
in another province or territory can submit their receipts to
Ontario adheres to the terms of the Interprovincial Agreement
MOHLTC for payment at Ontario rates.
on Eligibility and Portability; therefore, insured residents
who are temporarily outside of Ontario can use their Ontario
health cards to obtain insured physician (except in Quebec)
and hospital services.
Outside Canada
An insured person who leaves Ontario temporarily to travel
within Canada, without establishing residency in another Residents may be temporarily outside of Canada for a total
province or territory, may continue to be covered by OHIP of 212 days in any 12 month period and still maintain
for a period of up to 12 months. OHIP coverage as long as their primary place of residence
remains Ontario.
An insured person who temporarily seeks or accepts employment
in another province or territory may continue to be covered by
Extended Absences:
OHIP for a period of up to 12 months. If the individual plans
to remain outside Ontario beyond the 12 month maximum, Health insurance coverage for insured Ontario residents during
he or she should apply for coverage in the province or territory extended absences (longer than 212 days) outside Canada is
where that person has been working or seeking work. governed by Regulation 552 of the Health Insurance Act.
The MOHLTC requests that residents apply to MOHLTC

to confirm this coverage before their departure and provide
documents explaining the reason for their absence.

CHAPTER 3: ONTARIO
In accordance with regulations and MOHLTC policy, most During 2014–2015, out-of-country emergency, medically
applicants must also have been residents in Ontario for at least necessary, out-of-country physician services were reimbursed
153 days in each of the two consecutive 12 month periods at the Ontario rates set out in Regulation 552 under the
before their expected date of departure. Health Insurance Act or the amount billed, whichever was less.
The length of time that a person can receive continuous Ontario

health insurance coverage during an extended absence out- 4.4 Prior Approval Requirement
side Canada varies depending on the reason for the absence
as follows: As set out in Regulation 552 under the Health Insurance Act,
written prior approval from MOHLTC is required for payment
for non-emergency health services provided outside of Canada
Reason OHIP Coverage prior to the medical services being rendered.
Study Duration of full-time academic studies The prior approval application which includes written
(unlimited)
confirmation from the referring Ontario physician must
Work Five-year terms (specific residency establish that the services or tests are:
requirements must be met for 2 years
between absences) ■■ medically necessary;
■■ performed at an out-of-country licensed hospital or health
Charitable Worker Five-year terms (specific residency facility (as defined in the Regulations);
requirements must be met for 2 years
between absences) ■■ not experimental or for the purposes of research or a survey;
Vacation/Other Two-year terms (specific residency

■■ generally accepted by the medical profession in Ontario as
requirements must be met for 5 years appropriate for a person in the same medical circumstances
between absences) as the insured person; and either
−− not performed in Ontario by an identical or equivalent
procedure or
Certain family members may also qualify for continuous OHIP −− performed in Ontario but the insured person must travel
coverage while accompanying the primary applicant on an outside of Canada to avoid delay that would result in
extended absence outside Canada. death or medically significant irreversible tissue damage.
Out-of-Country Coverage for Ontario Residents who Except in an emergency, written prior approval of payment
must be granted by the General Manager before any of the
are Temporarily Absent health services are rendered.
Payment of out-of-country services for Ontarians who are
Requests for prior approval of funding require the endorsement
temporarily absent from Canada, such as for travelling, are
of a physician who is a specialist in the type of services for
captured under Regulation 552 of the Health Insurance Act.
which prior approval has been requested. This requirement
Out-of-country costs are for hospital and health facility services does not apply to emergency services and services that are
required to treat a condition that is acute and unexpected, arose within a general practitioner’s scope of practice.
outside of Canada, and requires immediate treatment. They
There are also other specified requirements in section 28.4
are reimbursed at rates set out in Regulation 552 under the
of Regulation 552 depending on the nature of the service for
Health Insurance Act:
which funding is requested.
■■ a maximum $400 (CAD) for in-patient services for a
Funding requirements for non-emergency laboratory tests
higher level of care as described in the Regulations and
performed outside Canada are described in section 28.5 of
$200 (CAD) for any other level of care;
Regulation 552 of the Health Insurance Act.
■■ a maximum $50 (CAD) for out-patient services (except
dialysis); and During 2014–2015 there was no formal prior approval required
for services provided to eligible Ontario residents outside the
■■ a maximum of $210 (CAD) for renal dialysis.
province, but within Canada, if the insured service is covered
under the Reciprocal Hospital Billing Agreements.

CHAPTER 3: ONTARIO
5.0 ACCESSIBILITY Acute care priority services include:
■■ selected cardiovascular services;
5.1 Access to Insured Health Services ■■ selected cancer services;

■■ chronic kidney disease services;
All insured hospital, physician and surgical-dental services are
available to Ontario residents on uniform terms and conditions. ■■ critical care services; and
■■ organ and tissue donation and transplantation.
All insured persons are entitled to all insured physician,
surgical-dental and hospital services, as defined in the Health Primary Health Care: During 2014–2015, consistent with
Insurance Act and regulations. the government direction outlined in Patients First: Action
Plan for Healthcare 2015, Ontario continued to align its new
Access to insured services is protected under Part II of the and existing primary health care delivery models to help
Commitment to the Future of Medicare Act (CFMA), “Health improve and expand access to primary health care physi-
Services Accessibility.” The CFMA prohibits any person or cian services for all Ontarians. The various primary health
any entity from charging or accepting payment or other benefit care physician compensation models encourage access to
for an insured service rendered to an insured person except as comprehensive primary health care services for Ontario as a
permitted in the CFMA. In addition, the CFMA prohibits whole, as well as for targeted population groups and remote
physicians, practitioners and hospitals from refusing to provide under-serviced communities.
an insured service if an insured person chooses not to pay a
“block fee” for an uninsured service. The CFMA further pro- Health Care Connect (HCC): HCC helps Ontarians who are
hibits any person or entity from paying, conferring, charging, or without a primary health care provider (family doctor or nurse
accepting a payment or other benefit in exchange for preferred practitioner) to find one. Insured persons without a primary
access for an insured person to an insured service. health care provider who register with HCC may be referred
to a family doctor or a nurse practitioner if there is an available
The Ministry of Health and Long-Term Care (MOHLTC) provider who is accepting new patients in their community.
investigates all possible contraventions of Part II of the CFMA
that come to its attention. For situations in which it is found During 2014–2015, MOHLTC continued to administer
that a patient has been extra-billed, the MOHLTC ensures various initiatives in order to improve access to health care
that the amount is repaid to that patient. services across the province. Ontario has taken steps to stabilize
physician supply through evidence-informed planning, and has
Health Card Validation (HCV) assists health care providers enhanced the retention and distribution of physicians in the
with access to information requested for claims payment. HCV province by taking such measures as:
allows the provider to determine the point-in-time status of a
patient’s Ontario health number (and version code) indicating ■■ stabilizing the significant expansion in medical education
eligibility or ineligibility for provincially funded health care since 2003;
services, thereby reducing claim rejects. A health care provider
■■ supporting rural and remote clinical education opportunities
may subscribe for validation services if they have a valid
for medical students;
and active billing number as assigned by the MOHLTC. If
patients require access to insured services and do not have a ■■ supporting the Northern Ontario School of Medicine;
valid health card in their possession, upon obtaining patient ■■ supporting training and assessment programs for
consent, the provider may obtain the necessary information by International Medical Graduates and other qualified
utilizing the accelerated health number release service provided physicians who do not meet certain requirements for
by ServiceOntario’s Health Number Look Up service which practice in Ontario; and
is offered 24 hours a day, 365 days per year to physicians or
hospitals registered for this service. ■■ supporting the HealthForceOntario Marketing and
Recruitment Agency to help recruit and retain health care
Acute care priority services are designated, highly specialized, professionals in Ontario communities that need them.
hospital-based services that deal with life-threatening
conditions such as organ transplants, cancer surgery and There are a number of existing initiatives to improve
treatments, and neuroservices. These services are often access across Ontario, including but not limited to the
high-cost and are rapidly growing, which has made access a HealthForceOntario Northern and Rural Recruitment and
concern. Generally, these services are managed provincially, Retention Initiative (NRRRI), the Northern Physician
on a time-limited basis. Retention Initiative (NPRI), and the Northern Health Travel
Grant (NHTG) Program.

CHAPTER 3: ONTARIO
■■ Northern and Rural Recruitment and Retention Family Health Teams (FHTs) are independent, non-profit
Initiative (NRRRI): The NRRRI supports the recruit- organizations that provide interdisciplinary team-based
ment and retention of physicians in rural and northern primary health care; they are staffed by providers such as nurse
communities. The NRRRI provides financial recruitment practitioners, nurses, social workers and dieticians. Physician
incentives to physicians who establish a full-time practice groups that can affiliate with and participate in FHTS are
in an eligible community. Community eligibility for the funded by one of three compensation options: Blended
NRRRI is based on a Rurality Index for Ontario score Capitation (such as FHN or FHO), Complement Based
of 40 or more. Also eligible are the five Northern Ontario Models (RNPGA or other specialized agreements) and BSM
Census Urban Referral Centre census metropolitan areas (for community sponsored FHTs). FHTs are located across
(Thunder Bay, Sudbury, North Bay, Sault Ste. Marie Ontario, in both urban and rural settings, ranging in size,
and Timmins). structure, scope and governance.
■■ Northern Physician Retention Initiative (NPRI): The MOHLTC negotiates many elements of physician com-
NPRI provides physicians who have completed a minimum pensation with the Ontario Medical Association (OMA).
of four years of continuous full-time practice in Northern The last Physician Services Agreement (PSA) expired on
Ontario with a $7,000 retention incentive paid at the end of March 31, 2014 and the MOHLTC and the OMA commenced
each fiscal year in which they continue to practice full-time negotiations for a new PSA in January 2014. The MOHLTC
in Northern Ontario. NPRI supports retention of physicians and the OMA negotiated from January 2014 to January 2015,
in Northern Ontario and encourages them to maintain but they were unsuccessful in reaching a PSA. In the absence
active hospital privileges. Northern Ontario is defined as of a new PSA, the MOHLTC implemented a set of initiatives
the districts of Algoma, Cochrane, Kenora, Manitoulin, (Ten-Point Plan for Saving and Improving Service) to change
Nipissing, Parry Sound, Muskoka, Rainy River, Sudbury, the funding for certain physician services and programs.
Thunder Bay and Timiskaming. The MOHLTC continues to work with the OMA in hopes
■■ Northern Health Travel Grant (NHTG) Program: that a new PSA can be agreed upon.
The NHTG Program helps defray travel-related costs
for residents of Northern Ontario who must travel long
distances to access insured medical specialist services, or 5.3 Payments to Hospitals
designated health care facility-based procedures that are
not locally available, within a radius of 100km. The NHTG Ontario hospitals are funded through a mix of base funding,
Program also promotes using specialist services located in which is on-going funding, and one-time funding. The majority
Northern Ontario, which encourages more specialists to of funding provided to hospitals is through base funding, which
practice and remain in the north. is comprised of several buckets of funding, including:
■■ Health System Funding Reform (HSFR);

5.2 Physician Compensation ■■ Global;
■■ Post-Construction Operating Plan (PCOP);
Physicians are paid for the services they provide through a
number of mechanisms. Some physician payments are provided ■■ Wait Times; and
through fee-for-service arrangements. Remuneration is based ■■ Priority Programs
on the Schedule of Benefits under the Health Insurance Act.
Other physician payment models include Primary Health On April 1, 2012, Ontario began the implementation of
Care Models (such as blended capitation models), Alternate the Health System Funding Reform (HSFR) Strategy for
Payment Plans, and new funding arrangements for physicians funding hospitals. HSFR shifts health care funding from
in Academic Health Science Centres. a predominantly global budget system towards an activity-
based funding model which ensures that patients get the right
In 2014–2015, 97 percent of General Practitioners received care, at the right place, at the right time and at the right price.
fee-for-service payments from OHIP, but fewer than HSFR offers an integrated approach to health system funding
30 percent of them were paid solely on a fee-for-service and puts the patient at the core through adopting a ‘money
basis. The majority (70 percent) of primary care physicians in follows the patient’ principle. HSFR is a significant shift from
Ontario received funding through one of the primary health the way Ontario hospitals were traditionally funded, which
models: Comprehensive Care (CCM), Family Health Group was largely based on historically-derived global budgets which
(FHG), Family Health Network (FHN), Family Health were established in 1969.
Organization (FHO), Community Health Centres (CHC),
Rural and Northern Physician Group Agreement (RNPGA),
Group Health Centre (GHC), Blended Salary Model (BSM),
and specialized agreements.

CHAPTER 3: ONTARIO
HSFR is comprised of two key components: Health Based facility expansions associated with approved capital projects.
Allocation Model (HBAM) and Quality-Based Procedures Ontario’s Wait Time Strategy provides targeted funding to
(QBP) funding, which together will comprise 50 percent of improve access to key health services by reducing wait times.
hospital’s total funding in 2015–2016 (38 percent HBAM; Provincial Program funding supports programs such as
12 percent QBP). certain specialized cardiac services, that are managed at a
provincial rather than regional level.
Health-Based Allocation Model: Is an evidence-based,
health-based funding formula. HBAM enables the government Hospital Service Accountability Agreements (H-SAA):
to equitably allocate available funding at the organizational When the Local Health Integration Networks (LHINs)
level to health service providers. HBAM uses an algorithm to assumed responsibility for their local health care systems they
identify a health service provider’s future expense levels. A set negotiated two year H-SAAs with their respective hospitals
funding pot is then divided amongst providers based on this and became the lead for the Hospital Annual Planning
future expense calculation and available funding. A health Submissions, which are the precursors to the H-SAAs. The
system provider’s future expense is determined based on past LHINs have amended the 2008/09–2009/10 H-SAA each year
patient services delivered and efficiency, as well as population from 2010/11 to 2014/15 versus negotiating a new two year
and health information, such as: age, gender, population agreement. These are referred to as Amending Agreements.
growth rates, diagnosis and procedures. Each of the hospitals
funded under HBAM receive a share of a fixed pot of funding. Public hospitals submit planning submissions to the
LHINs that are the result of broad consultations within the
Quality-Based Procedures: QBPs are an integral part of organizations (all levels of staff, unions, physicians and board),
HSFR as they align funding with quality improvement. They the community and region. Some of the data submitted in the
target clusters of patients with clinically related diagnoses or planning submissions are used to populate schedules for service
treatments that have been identified by an evidence-based volumes and performance targets that form the contractual
framework as providing opportunity for process improvements, basis for the H-SAA.
clinical redesign improved patient outcomes, enhanced patient
experience and potential cost savings. QBPs allow the health The H-SAA outlines the terms and conditions of the services
system to achieve better quality and system efficiencies through provided by the hospital, the funding it will receive, along with
utilizing a ‘price x volume x quality’ approach. The price for the performance and service levels expected. There are various
each patient group is currently based on the average price of performance indicators that are monitored, managed and
providing care, adjusted for patient acuity. evaluated in the agreement.
Global budgets (non-HSFR) will continue to be used for

activities that cannot be modeled, including those are that 6.0 RECOGNITION GIVEN TO
are unique (such as forensic mental health), or where HSFR
would introduce significant funding instability (such as FEDERAL TRANSFERS
small hospitals).
The Government of Ontario publicly acknowledged the federal
Additional buckets of funding are hospital-specific. The contributions provided through the Canada Health Transfer in
Post-Construction Operating Plan (PCOP) Program its Public Accounts of Ontario 2014–2015.
provides operational funding to support the service and

CHAPTER 3: ONTARIO
REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
1. Number as of March 31st (#). 13,100,000 1

13,212,728 1
13,349,791 1
13,452,921 1
13,545,565 1

2. Number (#). 149 2

147 2
146 2
145 2
145 2
3. Payments for insured health services ($). 15,527,899,500 3

16,173,889,100 3
16,418,200,000 3
16,361,203,000 3
16,377,339,000 3

providing insured health services (#). not available 4
not available 4
not available 4
not available 4
not available 4

for insured health services ($). not available 4
not available 4
not available 4
not available 4
not available 4

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA 5

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

CHAPTER 3: ONTARIO

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
16. Number of not participating physicians (#). 6 0 0 0 0 0

methods ($).7 10,374,311,208 11,008,532,900 11,228,719,988 11,379,311,227 11,823,825,604

physicians paid through fee-for-service ($). 7,052,261,365 7,508,636,523 7,402,377,170 7,600,334,259 7,784,933,027

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 25,237,480 25,252,852 26,017,930 30,248,528 31,360,835

22. Total payments ($). 12,455,597 7,922,281 6,537,845 5,844,999 6,473,814

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
25. Total payments ($). 13,525,890 13,532,519 12,525,404 12,713,974 12,040,331
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 2010–2011, 2011–2012, 2012–2013, 2013–2014, and 2014–2015 agree with Public Accounts.

MANITOBA
INTRODUCTION ■■ Improved access and quality of primary health care,

including development of Quick Care clinics, primary care
Manitoba Health, Healthy Living and Seniors (MHHLS) mobile clinics, the Advanced Access program, My Health
provides leadership and support to protect, promote and Teams and further enhancements to the Family Doctor
preserve the health of all Manitobans. MHHLS continues Finder program.
efforts to improve access, service delivery, capacity, innovation, ■■ Released “Advancing Continuing Care — A Blueprint
sustainability and improve the health status of Manitobans to Support System Change,” which outlines priority
while reducing health disparities. The roles and responsibilities actions in continuing care to meet the needs of individuals
of the department include policy, program and standards and families.
development; fiscal and program accountability; and evaluation.
In addition, specific direct services continue to be provided
through Selkirk Mental Health Centre, Cadham Provincial
Laboratory, public health inspections, and provincial
1.0 PUBLIC ADMINISTRATION
nursing stations.
MHHLS remains committed to the principles of Medicare and

1.1 Health Care Insurance Plan and
improving the health status of all Manitobans. In 2014–2015 Public Authority
Manitoba continued to support these commitments through the
following activities: The Manitoba Health Services Insurance Plan (MHSIP)
is administered by Manitoba Health, Healthy Living and
■■ Negotiated agreements with Doctors Manitoba, Manitoba Seniors (MHHLS) under the Health Services Insurance Act,
Nurses Union (MNU), and other health professional R.S.M. 1987, c. H35.
associations. The Doctors Manitoba and MNU agreements
include provisions for collaboration on health system The MHSIP is administered under this Act and insures
improvements and efficiencies. the costs of hospital, personal care, and medical and other
health services referred to in acts of the Legislature or
■■ Increased the overall number of specialist physicians, related regulations.
general practitioners, registered nurses, nurse practitioners,
registered psychiatric nurses, and licensed practical nurses. The Minister of Health is responsible for administering and
■■ Partnered with Manitoba Blue Cross to launch a modernized operating the MHSIP. The Minister may also enter into
medical claims processing system. contracts and agreements with any person or group that he
or she considers necessary for the purposes of the Act.
■■ Expanded, streamlined and increased efficiencies of the
Electronic Medical Record (EMR) Repository, with The Minister may also make grants to any person or group
over 130 (and growing) primary care clinics regularly for the purposes of the Act on such terms and conditions that
submitting EMR data. are considered advisable. Also, the Minister may, in writing,
■■ Continued to collaborate with the Winnipeg Regional delegate to any person any power, authority, duty or function
Health Authority and CancerCare Manitoba on the conferred or imposed upon the Minister under the Act or under
implementation of the cancer treatment access strategy the regulations.
entitled, “Transforming the Cancer Patient Journey in There were no legislative amendments to the Act or the
Manitoba,” which aims to reduce the time from suspicion regulations in the 2014–2015 fiscal year that affected the
to treatment to two months or less. public administration of the MHSIP.

CHAPTER 3: MANITOBA
1.2 Reporting Relationship Manitoba residents maintain high expectations for quality health
care and insist that the best available medical knowledge and
Section 6 of the Health Services Insurance Act requires the service be applied to their personal health situations.
Minister to have audited financial statements of the MHSIP
showing separately the expenditures for hospital services,
medical services and other health services. The Minister is 2.2 Insured Physician Services
required to prepare an annual report, which must include the
audited financial statements, and to table the report before The enabling legislation that provides for insured physician
the Legislative Assembly within 15 days of receiving it, services is the Medical Services Insurance Regulation
if the Assembly is in session. If the Assembly is not in session, (M.R. 49/93) made under the Health Services Insurance Act.
the report must be tabled within 15 days of the beginning of
Physicians providing insured services in Manitoba must be
the next session.
lawfully entitled to practice medicine in Manitoba, and be
registered and licensed under the Medical Act.
1.3 Audit of Accounts The number of medical practitioners registered with MHHLS
to provide insured services as of March 31, 2015 was 2,510.
Section 7 of the Health Services Insurance Act requires that
the Office of the Auditor General of Manitoba (or another A physician, by giving notice to the Minister in writing,
auditor designated by the Office of the Auditor General of may elect to collect the fees other than from the Minister for
Manitoba) audit the accounts of the MHSIP annually and medical services rendered to insured persons, in accordance
prepare a report on that audit for the Minister. The most with section 91 of the Act and section 5 of the Medical
recent audit reported to the Minister and available to the Services Insurance Regulation. The election to opt out of
public is for the 2014–2015 fiscal year and is contained in the the health insurance plan takes effect on the first day of the
Manitoba Health Annual Report, 2014–2015. It is available month following a 90-day period from the date the Minister
at www.gov.mb.ca/health/ann/index.html. receives the notice.
Before rendering a medical service to an insured person,

2.0 COMPREHENSIVENESS physicians must give the patient reasonable notice that they
propose to collect any fee for the medical service from them
or any other person except the Minister. The physician is
2.1 Insured Hospital Services responsible for submitting a claim to the Minister on the
patient’s behalf and cannot collect fees in excess of the
Sections 46 and 47 of the Health Services Insurance Act, as benefits payable for the service under the Act or Regulations.
well as the Hospital Services Insurance and Administration
Regulation (M.R. 48/93), provide for insured hospital services. No physicians opted out of the medical plan in 2014–2015.
As of March 31, 2015, there were 96 facilities providing The range of physician services insured by MHHLS is listed
insured hospital services to both in-patients and out-patients. in the Payment for Insured Medical Services Regulation
Hospitals are designated by the Hospitals Designation (M.R. 95/96). Coverage is provided for all medically required
Regulation (M.R. 47/93) under the Act. personal health care services that are not excluded under
the Excluded Services Regulation (M.R. 46/93) of the Act,
Services specified by the Regulation as insured in-patient rendered to an insured person by a physician.
and out-patient hospital services include: accommodation and
meals at the standard ward level; necessary nursing services; During fiscal year 2014–2015, a number of new insured services
laboratory, radiological and other diagnostic procedures; drugs, were added to a revised fee schedule. The Physician’s Manual,
biologics and related preparations; routine medical and surgical including all insured medical services, can be viewed on-line at:
supplies; use of operating room, case room and anaesthetic www.gov.mb.ca/health/manual/index.html.
facilities; and use of radiotherapy, physiotherapy, occupational
and speech therapy facilities where available. The process for a medical service to be added to the list of
those covered by MHHLS is that physicians must put forward
The Regulation states that hospital in-patient services include a proposal to their specific section of Doctors Manitoba.
routine medical and surgical supplies, thereby ensuring reasonable Doctors Manitoba will negotiate the item, including the fee,
access for all residents. The regional health authorities and with MHHLS. MHHLS may also initiate this process.
Manitoba Health, Healthy Living and Seniors (MHHLS)
monitor compliance.

CHAPTER 3: MANITOBA
2.3 Insured Surgical-Dental Services No services were removed from the list of those insured by
MHHLS in 2014–2015.
Insured surgical and dental services are listed in the
Hospital Services Insurance and Administration Regulation
(M.R. 48/93) under the Health Services Insurance Act. Surgical 3.0 UNIVERSALITY
services are insured when performed by a certified oral and
maxillofacial surgeon or a licensed dentist in a hospital, when
hospitalization is required for the proper performance of the 3.1 Eligibility
procedure. This Regulation also provides benefits relating to
the cost of insured orthodontic services in cases of cleft lip The Health Services Insurance Act defines the eligibility of
and/or palate for persons registered under the program by their Manitoba residents for coverage under the provincial health
18th birthday, when provided by a registered orthodontist. care insurance plan.
Providers of dental services may elect to collect their fees Section 2(1) of the Act states that a resident is a person who
directly from the patient in the same manner as physicians is legally entitled to be in Canada, makes his or her home
and may not charge to, or collect from, an insured person a fee in Manitoba, is physically present in Manitoba for at least
in excess of the benefits payable under the Act or regulations. six months in a calendar year, and includes any other person
No providers of dental services had opted out in 2014–2015. classified as a resident in the regulations, but does not include
a person who holds a temporary resident permit under the
In order for a dental service to be added to the list of insured Immigration and Refugee Protection Act (Canada), unless
services, a dentist must put forward a proposal to the Manitoba the Minister determines otherwise, or is a visitor, transient
Dental Association (MDA). The MDA negotiates the item and or tourist.
fee with MHHLS.
The Residency and Registration Regulation (M.R. 54/93)
extends the definition of residency. The extensions are found
2.4 Uninsured Hospital, Physician and in sections 7(1) and 8(1). Section 7(1) allows missionaries,
individuals with out-of-country employment and individuals
Surgical-Dental Services undertaking sabbatical leave to be outside Manitoba for up
The Excluded Services Regulation (M.R. 46/93) made under to two years while still remaining residents of Manitoba.
the Health Services Insurance Act sets out those services that are Students are deemed to be Manitoba residents while in full-time
not insured. These include: examinations and reports for reasons attendance at an accredited educational institution. Section 8(1)
of employment, insurance, attendance at university or camp, or extends residency to individuals who are legally entitled to work
performed at the request of third parties; group immunization in Manitoba and have a work permit of 12 months or more and
or other group services except where authorized by MHHLS; to individuals who hold study permits of six months or more
services provided by a physician, dentist, chiropractor or under the Immigration and Refugee Protection Act (Canada).
optometrist to him or herself or any dependants; preparation Additionally, section 8.1.1 of the Residency and Registration
of records, reports, certificates, communications and testimony Regulation extends deemed residency to temporary foreign
in court; mileage or travelling time; services provided by workers (and their dependants) in the province to provide
psychologists, chiropodists and other practitioners not provided agricultural services on the basis of a work permit, regardless
for in the legislation; in vitro fertilization; tattoo removal; of the duration of their work permit.
contact lens fitting; reversal of sterilization procedures; and
The Residency and Registration Regulation, section 6, defines
psychoanalysis.
Manitoba’s waiting period as follows:
All Manitoba residents have equitable access to services. Third
“A resident who was a resident of another Canadian
parties such as private insurers or the Workers Compensation
province or territory immediately before his or her arrival
Board do not receive priority access to services through
in Manitoba is not entitled to benefits until the first day
additional payment. Manitoba has no formalized process
of the third month following the month of arrival.”
to monitor compliance; however, feedback from physicians,
hospital administrators, medical professionals and staff allows Section 6 of the Residency and Registration Regulation
regional health authorities and MHHLS to monitor usage and stipulates that there is no waiting period for dependants
service concerns. of members of the Canadian Armed Forces.
To de-insure services covered by MHHLS, the Ministry There are currently no other waiting periods in Manitoba.
prepares a submission for approval by Cabinet. The need
for public consultation is determined on an individual basis
depending on the subject.

CHAPTER 3: MANITOBA
The Manitoba Health Services Insurance Plan (MHSIP) dependants) holding a valid study permit with a duration
excludes residents covered under any federal plan, including the of 12 months or more.
following federal statutes: Aeronautics Act; Civilian War-related
Benefits Act; Government Employees Compensation Act; Merchant Section 8.1.1 of the Residency and Registration Regulation
Seaman Compensation Act; National Defence Act; Pension Act; extends deemed residency to temporary foreign workers
Veteran’s Rehabilitation Act; federal inmates or those covered (and their dependants) in the province to provide agricultural
under legislation of any other jurisdiction (Excluded Services services on the basis of a work permit, regardless of the
Regulations subsection 2(2)). These residents become eligible duration of their work permit.
for health services insurance coverage upon discharge from the
Canadian Forces, or in the case of an inmate of a penitentiary,
upon discharge if the inmate has no resident dependants. Upon 4.0 PORTABILITY
change of status, these persons have one month to register with
Manitoba Health, Healthy Living and Seniors (MHHLS)
(Residency and Registration Regulation (M.R. 54/93, 4.1 Minimum Waiting Period
subsection 2(3)).
The Residency and Registration Regulation (M.R. 54/93,
RCMP members are insured persons in Manitoba and are section 6) identifies the waiting period for insured persons from
eligible for benefits under the MHSIP. another province or territory. A resident who lived in another
Canadian province or territory immediately before arriving
The process of issuing health insurance cards requires that in Manitoba is entitled to benefits on the first day of the
individuals inform and provide documentation to MHHLS third month following the month of arrival.
that they are legally entitled to be in Canada, and that they
intend to be physically present in Manitoba for six months in
a calendar year. They must also provide a primary residence 4.2 Coverage During Temporary Absences
address in Manitoba. Upon receiving this information,
MHHLS will provide a registration card for the individual
in Canada
and all qualifying dependants. The Residency and Registration Regulation (M.R. 54/93
section 7(1)) defines the rules for portability of health
Manitoba has two health-related numbers. The registration
insurance during temporary absences in Canada.
number is a six-digit number assigned to an individual 18 years
of age or older who is not classified as a dependant. This number Students are considered residents and will continue to
is used by MHHLS to pay for all medical service claims for that receive health coverage for the duration of their full-time
individual and all designated dependants. A nine-digit Personal enrolment at any accredited educational institution. The
Health Identification Number (PHIN) is used for payment of additional requirement is that they intend to return and
all hospital services and for the provincial drug program. reside in Manitoba after completing their studies. Manitoba
has formal agreements with all Canadian provinces and
As of March 31, 2015, there were 1,317,861 residents registered
territories for the reciprocal billing of insured hospital services.
with the MHSIP.
In-patient costs are paid at standard rates approved by the
There is no provision for a resident to opt out of the MHSIP.
host province or territory. Payments for in-patient, high-cost
procedures and out-patient services are based on national rates
agreed to by provincial and territorial health plans. These
3.2 Other Categories of Individuals include all medically necessary services as well as costs for
The Residency and Registration Regulation (M.R. 54/93, emergency care.
sub-section 8(1)) requires that temporary workers possess a
Except for Quebec, medical physician services incurred in all
work permit issued by Citizenship and Immigration Canada
provinces or territories are paid through a reciprocal billing
for at least 12 consecutive months, be physically present in
agreement at host province or territory rates. Claims for
Manitoba for six months in a calendar year, and be legally
physician medical services received in Quebec are submitted
entitled to be in Canada before receiving MHSIP coverage.
by the patient or physician to Manitoba Health, Healthy Living
Section 8.1(a.1) of the Residency and Registration Regulation and Seniors (MHHLS) for payment at host province rates.
extends deemed residency to foreign students (and their

CHAPTER 3: MANITOBA
4.3 Coverage During Temporary Absences 5.0 ACCESSIBILITY

Outside Canada
The Residency and Registration Regulation (M.R. 54/93, sub- 5.1 Access to Insured Health Services
section 7(1)) defines the rules for portability of health insurance
during temporary absences from Canada. Manitoba Health, Healthy Living and Seniors (MHHLS)
ensures that medical services are equitable and reasonably
Section 7(1)(g) of the Residency and Registration Regulation available to all Manitobans. Effective January 1, 1999,
extends the period during which a person may be temporarily the Surgical Facilities Regulation (M.R. 222/98) under
absent from Manitoba for the purpose of residing outside of the Health Services Insurance Act came into force to prevent
Canada from six months to a maximum of seven months in private surgical facilities from charging additional fees for
a 12-month period. insured medical services.
Residents on full-time employment contracts outside Canada The Health Services Insurance Act, the Private Hospitals Act and
will receive health services insurance coverage for up to the Hospitals Act include definitions and other provisions
24 consecutive months. Individuals must return and reside in to ensure:
Manitoba after completing their employment terms. Clergy
serving as humanitarian aid workers or missionaries on behalf ■■ that no charges can be made to individuals who receive
of a religious organization approved as a registered charity insured surgical services, or to anyone else on that person’s
under the Income Tax Act (Canada) will be covered by MHHLS behalf; and
for up to 24 consecutive months. Students are considered ■■ that a surgical facility cannot perform procedures requiring
residents and will continue to receive health coverage for overnight stays and thereby function as a private hospital.
the duration of their full-time enrollment at an accredited
educational institution. The additional requirement is that MHHLS continues to invest in improving clients’ access. To
they intend to return and reside in Manitoba after completing achieve Manitoba’s commitment that all Manitobans who wish
their studies. Residents on sabbatical or educational leave to will have access to a family physician, investments continue
from employment will be covered by MHHLS for up to to be made in initiatives such as Primary Care Networks
24 consecutive months. These individuals also must return and inter-professional teams. In addition, Manitoba opened
and reside in Manitoba after completing their leave. a fifth Quick Care Clinic; operated two mobile clinics, one
in the Prairie-Mountain Regional Health Authority (RHA)
Manitobans requiring medically necessary hospital services and the other in the Southern Health-Santé Sud RHA; and
unavailable in Manitoba or elsewhere in Canada may be eligible introduced more opportunities and supports for Manitobans
for costs incurred in the United States by providing MHHLS to self-manage their health care. Investment also continued in
with a recommendation from a specialist stating that the existing initiatives that enhance capacity, quality and efficiency
patient requires a specific, medically necessary service. in primary care, such as the Physician Integrated Network,
TeleCARE Manitoba (a chronic disease self-management
resource for congestive heart failure and diabetes), and an
4.4 Prior Approval Requirement After-Hours Call Community Network (a network of general
practitioners linked to patients through the 24-hour Health
Prior approval is not required for procedures that are covered
Links-Info Santé service).
under the interprovincial reciprocal agreements with other
provinces. Prior approval by MHHLS is required for high Since 2008, MHHLS funded and coordinated over 90 primary
cost items or procedures that are not included in the reciprocal clinics, regional community programs and specialty clinics
agreements. to successfully complete the Advanced Access training,
enabling them to offer patients same-day access to a primary
All non-emergency hospital and medical care provided outside
care provider and five-day access to a specialist or community
Canada requires prior approval from MHHLS.
program. Since 2013, the redeveloped Family Doctor Finder
program has enabled Manitobans to call or e-mail to be
registered and connected with a primary care provider. This
includes Regional Primary Care Connectors, who work
with regional primary care providers to find capacity in their
practices to see new patients. To date, over 28,000 Manitobans
without a provider have found one through the program.

CHAPTER 3: MANITOBA
The Cancer Patient Journey initiative was established in 2011 under one umbrella institute which has resulted in cross
to streamline cancer services and dramatically reduce the wait talk, efficiency and awareness of all cancer research while
time for patients between the time cancer is suspected and the also including the patient experience and prevention.
start of effective treatment to two months or less. Key initiative ■■ Increasing the number of medical oncologists with
activities to date include: a special interest in gastro intestinal malignancies
■■ Facilitating the work of the Rapid Improvement Leads (including pancreatic cancers).
with stakeholders to identify process efficiencies and Other improvements in Cancer and Diagnostic care include:
improvements related to diagnosis and treatment.
■■ Opening of the Regional Cancer Program Hubs located in ■■ Plans to expand and renovate the Thompson Hospital’s
Thompson, The Pas, Steinbach and Winnipeg. These Cancer chemotherapy space providing a larger, more functional
Hubs are oncology out-patient units focused on delivering environment for patients and staff alike.
chemotherapy as well as providing navigation services, ■■ The preliminary design of a new CancerCare Building.
psychosocial support and enhanced access to clinical
■■ Additional renal dialysis capacity was added through
expertise. They serve to expedite cancer diagnosis and
funding for an additional four stations to provide service
treatment for people inside and outside Winnipeg.
to 24 patients in Winnipeg.
■■ Clinical pathways for breast and colorectal cancer for
■■ Additional MRI capacity was added through expansion
suspicion of cancer to treatment were completed with
of service hours.
broad consultation and validation among clinicians.
■■ Expansion of after hours and emergency diagnostic testing
■■ Patient trackers were hired to track a patient’s journey
for computed tomography in rural Manitoba.
from suspicion of cancer to diagnosis.
■■ Provincial Lab Information System (PLIS) implementation
In November 2012 the province released an updated framework at 13 additional sites within Manitoba. The PLIS enables
“Manitoba’s Cancer Strategy 2012–2017” for cancer control electronic delivery of rural lab results to clinical data
that will guide actions to build on the major successes delivered repositories, emergency departments and to electronic
under the 2007 provincial cancer strategic framework. The medical records.
document, created with input from partners, stakeholders
■■ Replacement of Computed Radiography facilities at
and cancer patients themselves, outlines an integrated and
Ste. Anne, Minnedosa, Neepawa, Glenboro and Souris.
cohesive approach to cancer that involves prevention, screening,
This new equipment provides digital images that are
diagnosis, research, treatment, palliative care and survivorship.
sent to radiologists electronically resulting in improved
Key activities to date include:
turnaround times so that patients receive their test results
■■ Expanding the hours of the Urgent Care Clinic and Helpline faster and improved access for physicians to enhance
at CancerCare Manitoba (CCMB) to provide after-hours treatment planning.
support to Manitobans facing cancer. The Urgent Care Clinic
A three million dollar cross-departmental grant aimed at
assists patients with cancer-related complications and side-
improving the health and quality of life for Manitobans
effects from treatment, such as dehydration, pain, nausea,
living with spinal cord injury and related disabilities has
digestive issues, and fatigue. The helpline is a dedicated phone
been established.
line answered by registered nurses with oncology training,
to provide support and advice to cancer patients faced with Manitoba continues to experience growth in the number of
urgent issues and direct them to appropriate services. active practicing nurses. There were 17,806 active practicing
■■ The implementation of the provincial conversion of Film nurses in Manitoba in 2014. This represents a net gain of
Screen Mammography equipment to Digital Mammography. 11 nurses over 2013 (17,795).
■■ Implementing liquid based cytology as a platform for future A renewed Collective Agreement was reached with the
HPV testing in Manitoba. Manitoba Nurses’ Union (MNU) on April 9, 2014 and is in
■■ The development of cancer prevention concepts effect for four years, from April 1, 2013 to March 31, 2017.
including smoking cessation, genetic testing and The Agreement provides for wage increases of 10.1% over
radiation exposure legislation. four years, which breaks down as follows: 2% retroactively
for 2013; 2% in 2014 plus 1.1% market adjustment; 2% in 2015;
■■ Grant funding to assist in the service delivery of the Canadian
and 2% in 2016 plus a 1% market adjustment. As part of the
Cancer Society transportation program to ensure patients
new Agreement, the parties made a number of post-bargaining
receive transportation to cancer treatment and appointments
commitments, including the commitment to identify, develop
no matter where they live in the province.
and implement system delivery changes intended to improve
■■ The Research Institute of Oncology and Hematology at the effectiveness and efficiency of health care service delivery
CancerCare Manitoba consolidated all cancer researchers in Manitoba.

CHAPTER 3: MANITOBA
The Nurses Recruitment and Retention Fund, established in a salary (employment relationship) or those who work on
1999, continues to contribute to the nursing supply in terms of an independent contract basis. Manitoba also uses blended
both recruitment and retention in Manitoba. Financial support payment methods where appropriate. As well, physicians may
has continued to be provided in order to assist nurses of all receive sessional payments for providing medical services on
categories to offset the cost of relocating to work in Manitoba, a time based arrangement, as well as stipends for on-call and
as well as offering funding to encourage nurses to work in other responsibilities.
rural and northern regions and other areas of need in order
to enhance the delivery of health care across the province. Manitoba Health, Healthy Living and Seniors represents
Manitoba in negotiations with physicians. The physicians are
In addition to continued implementation of the overall healthcare typically represented by Doctors Manitoba with some exceptions,
transformation whereby more services may be provided in the such as oncologists engaged by CancerCare Manitoba.
community, in primary care settings, efforts will be undertaken
over the next few years to plan for addressing both the increasing Negotiations to renew the Master Agreement between Doctors
age of this workforce, in terms of retirements, as well as the Manitoba and Manitoba, which expired on March 31, 2015,
advancing age of the population in terms of the need for long took place during the 2014–2015 fiscal year.
term care services.
The Manitoba Physician’s Manual lists all of the fee tariff
The Province has been supporting the expansion of the descriptions, rates, rules of application and the dispute resolution
Physician Assistant (PA) role in Manitoba. PAs are highly process in relation to fee-for-service payments to physicians. This
skilled health care professionals who practice medicine under document is the Schedule of Benefits payable to physicians on behalf
the supervision of licensed physicians. PAs are regulated by of insured persons in Manitoba pursuant to the Medical Services
the College of Physicians & Surgeons of Manitoba (CPSM) Insurance Regulation under The Health Services Insurance Act.
and must be registered with the CPSM in order to practice
All fee-for-service claims must be submitted electronically. The
in Manitoba. The CPSM determines a PA’s specific scope
submission of paper claims is permitted on a limited basis and only
of practice by approving their practice description, which is
with the prior approval of Manitoba Health. Fee-for-service claims
signed by their supervising physician.
must be received within six months of the date upon which the
Since Manitoba established its PA Regulation in 1999 the role physician rendered the service.
of the PA has grown from positions with acute surgical units
During the 2014–2015 fiscal year, final preparations were made for
(general, orthopedic and cardiac) to having PAs providing
implementation of a new claims processing system to replace the
clinical support in areas of mental health, internal medicine,
legacy system which has been in use for over 40 years.
oncology and primary care. PAs working in primary care in
Manitoba have ranged from ‘solo’ practices in rural Manitoba,
supervised and supported by physicians in a nearby community,
to working in both regional health authority run primary
5.3 Payments to Hospitals
care clinics and community-based fee-for-service clinics. The Division 3.1 of Part 4 of the Regional Health Authorities Act sets
demand for PAs continues to grow as the profession has shown out the requirements for operating agreements between regional
great adaptability to address access and service challenges health authorities and the operators of hospitals and personal
throughout Manitoba’s health system. As of March 2015, care homes, defined as “health corporations” under the Act.
there were 65 PAs registered with the CPSM.
Pursuant to the provisions of division 3.1, regional health
authorities are prohibited from providing funding to a health
5.2 Physician Compensation corporation for operational purposes unless the parties have
entered into a written agreement for this purpose that: enables
Manitoba continues to employ the following methods of the health services to be provided by the health corporation;
payment for physicians: fee-for-service, contract, blended and enables the funding to be provided by the regional health
sessional. The Health Services Insurance Act governs remuneration authority for the health services; sets out the terms of the
to physicians for insured services. There were no amendments agreement; and includes a dispute resolution process and
to the Health Services Insurance Act related to physician remedies for breaches. If the parties cannot reach an agreement,
compensation during the 2014–2015 fiscal year. the Act enables them to request that the Minister of Health
appoint a mediator to help them resolve outstanding issues.
Fee-for-service remains the primary method of payment for
If the mediation is unsuccessful, the Minister is empowered
physician services. Alternate payment arrangements constitute
to resolve the matter or matters in dispute. The Minister’s
a significant portion of the total compensation to physicians
resolution is binding on the parties.
in Manitoba. Alternate-funded physicians are those who
receive non fee-for-service compensation, including through

CHAPTER 3: MANITOBA
There are three regional health authorities which have hospitals the regional health authorities. In relation to those hospitals
operated by health corporations in their health regions. The that are not owned and operated by a regional health authority,
regional health authorities have required agreements with the regional health authority is required to pay each hospital in
health corporations that enable the regional health authority accordance with any agreement reached between the regional
to determine funding based on objective evidence, best health authority and the hospital operator.
practices and criteria that are commonly applied to comparable
facilities. In all other regions, the hospitals are operated by the No legislative amendments to the Act or the regulations
Regional Health Authorities Act. Section 23 of the Act requires in 2014–2015 had an effect on payments to hospitals.
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 MHHLS through FEDERAL TRANSFERS
the approval of regional health plans, which the regional health
Manitoba regularly recognizes the federal role regarding
authorities are required to submit for approval pursuant to
the contributions provided under the Canada Health
section 24 of the Regional Health Authorities Act. Section 23
Transfer (CHT) in public documents. Federal transfers are
of the Act requires that authorities allocate their resources
identified in the Estimates of Expenditures and Revenue
in accordance with the approved regional health plan.
(Manitoba Budget) document and in the Public Accounts
Pursuant to subsection 50(2.1) of the Health Services Insurance of Manitoba. Both documents are published annually by
Act, payments from the Manitoba Health Services Insurance the Manitoba government.
Plan (MHSIP) for insured hospital services are to be paid to

CHAPTER 3: MANITOBA
REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
1. Number as of March 31st (#). 1,230,270 1,265,059 1,271,388 1,289,268 1,317,861

2. Number (#). 96 96 96 96 96
3. Payments for insured health services ($). not available not available not available not available not available


for insured health services ($). 1,541,540 2,005,150 1,928,985 2,040,914 not available

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015


CHAPTER 3: MANITOBA

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
16. Number of not participating physicians (#). not applicable not applicable not applicable not applicable not applicable

methods ($). 920,890,000 927,916,000 988,164,000 1,082,193,000 1,134,521,000


2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 9,909,927 10,989,977 11,127,080 11,137,758 11,963,709

22. Total payments ($). 953,272 703,353 1,148,432 888,084 1,048,275

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
25. Total payments ($). 1,522,545 1,468,524 1,231,972 1,493,071 2,083,453

SASKATCHEWAN
INTRODUCTION 1.0 PUBLIC ADMINISTRATION

Saskatchewan’s Ministry of Health strives to put patients
first by building a responsive, integrated, and efficient health 1.1 Health Care Insurance Plan and
system that enables people to achieve their best possible health.
The Ministry is exploring innovative approaches based on Public Authority
targets in four areas: better health, better care, better value, The provincial government is responsible for funding and
and better teams. The needs and values of patients and ensuring the provision of insured hospital, physician and
families are reflected in both planning and delivery of care, surgical-dental services in Saskatchewan. Section 6.1 of the
through a system-wide focus on quality improvement (Lean) Health Administration Act authorizes that the Minister of
management processes. Health may:
Saskatchewan’s health care system includes 12 regional health ■■ pay part of, or the whole of, the cost of providing health
authorities, the Saskatchewan Cancer Agency, eHealth services for any persons or classes of person who may be
Saskatchewan, 3sHealth (Shared Services Saskatchewan), designated by the Lieutenant Governor-in-Council;
the Athabasca Health Authority, affiliated health care
organizations, and a diverse group of professionals, many ■■ make grants or loans, or provide subsidies to regional health
of whom are in private practice. There are 26 self-regulated authorities, health care organizations or municipalities
health professions in the province and the health system as a for providing and operating health services or public
whole employs more than 40,000 people who provide a broad health services;
range of services. The Ministry provides governance training ■■ pay part of, or the whole of, the cost of providing health
and effective strategic oversight to the Boards of Directors services in any health region or part of a health region
of regional health authorities and the Saskatchewan Cancer in which those services are considered by the Minister
Agency and encourages leadership from boards, management, to be required;
and health professionals at all levels.
■■ make grants or provide subsidies to any health agency that
The Ministry also supports the efforts of regional health the Minister considers necessary; and
authorities, the Saskatchewan Cancer Agency, and other ■■ make grants or provide subsidies to stimulate and develop
stakeholders to recruit and retain health care providers, public health research, and to conduct surveys and studies
including nurses and physicians. Partnerships with local, in the area of public health.
regional, provincial, national and international organizations
are fundamental to providing all Saskatchewan residents with Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act
access to quality health care services. provide the authority for the Minister of Health to establish
and administer a plan of medical care insurance for residents.
Visit www.saskatchewan.ca for more information about The Regional Health Services Act, implemented in 2002, provides
Ministry programs and services. the authority to establish 12 regional health authorities.
Sections 3 and 9 of the Cancer Agency Act provide for

establishing a Saskatchewan Cancer Agency and for the
Agency to coordinate a program for diagnosing, preventing
and treating cancer.
The mandates of the Ministry of Health, regional health

authorities and the Saskatchewan Cancer Agency are outlined
in the Health Administration Act, the Regional Health Services Act
and the Cancer Agency Act.

CHAPTER 3: SASKATCHEWAN
1.2 Reporting Relationship The Office of the Provincial Auditor for Saskatchewan also
prepares reports to the Legislative Assembly of Saskatchewan.
The Ministry of Health is directly accountable, and regularly These reports are designed to assist the government in
reports, to the Minister of Health on the funding, and managing public resources and to improve the information
administering the funds, for insured physician, surgical-dental provided to the Legislative Assembly. They are available on
and hospital services. the Provincial Auditor’s website at: http://www.auditor.sk.ca.
Section 36 of the Saskatchewan Medical Care Insurance Act

requires that the Minister of Health submit an annual
report concerning the medical care insurance plan to the
2.0 COMPREHENSIVENESS
Legislative Assembly.
The Regional Health Services Act requires that each regional

2.1 Insured Hospital Services
health authority shall submit to the Minister of Health: Section 8 of the Regional Health Services Act gives the Minister
the authority to provide funding to a regional health authority
■■ a report on the activities of the regional health authority; and
or a health care organization for the purpose of the Act.
■■ a detailed, audited set of financial statements.
Section 10 of the Act permits the Minister to designate
Pursuant to legislation, these reports and corresponding facilities including hospitals, special care homes and health
statements are then provided by the Minister to the centres. Section 11 allows the Minister to prescribe standards
Legislative Assembly. for delivering services in those facilities by regional health
authorities and health care organizations that have entered into
Section 54 of the Regional Health Services Act requires that service agreements with a regional health authority.
regional health authorities and the Cancer Agency submit to
the Minister any reports that the Minister may request from The Act sets out the accountability requirements for regional
time to time. Regional health authorities and the Cancer health authorities and health care organizations. These
Agency are required to submit various financial documents and requirements include submitting annual financial and
a health service plan to the Saskatchewan Ministry of Health. health service plans for ministerial approval (section 51),
establishing community advisory networks (section 28), and
reporting critical incidents (section 58). The Minister also has
1.3 Audit of Accounts the authority to establish a provincial surgical registry to help
manage surgical wait times (section 12). The Minister retains
The Provincial Auditor conducts an annual audit of government authority to inquire into matters (section 59), appoint a public
ministries and agencies, including the Ministry of Health. administrator if necessary (section 60), and approve general
It includes an audit of Ministry payments including but not and staff practitioner by-laws (sections 42–44).
limited to regional health authorities, the Saskatchewan Cancer
Agency, and physicians and dental surgeons for insured Funding for hospitals is included in the funding provided to
physician and surgical-dental services. regional health authorities.
Section 57 of the Regional Health Services Act requires that an A comprehensive range of insured services is provided by
independent auditor, who possesses the prescribed qualification hospitals. These may include: public ward accommodation;
and is appointed for that purpose by a regional health authority necessary nursing services; the use of operating room and case
and the Cancer Agency, audit the accounts of a regional health room facilities; required medical and surgical materials and
authority or the Cancer Agency at least once in every fiscal year. appliances; x-ray, laboratory, radiological and other diagnostic
Each regional health authority and the Cancer Agency must procedures; radiotherapy facilities; anaesthetic agents and the
annually submit to the Minister of Health a detailed, audited use of anaesthesia equipment; physiotherapeutic procedures;
set of financial statements. all drugs, biological and related preparations required for
hospitalized patients; and services rendered by individuals
The most recent audits were for the year ending March 31, 2015. who receive remuneration from the hospital.
The audits of the Government of Saskatchewan, regional health
authorities and Saskatchewan Cancer Agency are tabled in the Hospitals are grouped into the following five categories:
Saskatchewan Legislature each year. The reports are available Community Hospitals; Northern Hospitals; District
to the public directly from each entity and are available on Hospitals; Regional Hospitals; and Provincial Hospitals,
their websites. so people know what they can expect at each hospital.
While not all hospitals will offer the same kinds of services,
reliability and predictability means:

■■ it is widely understood which services each hospital offers; A process of formal discussion between the Medical Services
and Plan and the Saskatchewan Medical Association addresses new
■■ these services will be provided on a continuous basis, subject insured physician services and definition or assessment rule
to the availability of appropriate health providers. revisions to existing selected services. The Executive Director
of the Medical Services Branch manages this process. When
Regional health authorities have the authority to change the the Medical Services Plan covers a new insured physician
manner in which they deliver insured hospital services based service, or revisions to definitions or assessment rules for
on an assessment of their population health needs, available existing services occur, a regulatory amendment is made
health providers and financial resources. to the Physician Payment Schedule.
The process for adding a hospital service to the list of services Although formal public consultations are not held, any member
covered by the health care insurance plan involves a compre of the public may make recommendations about physician
hensive review, which takes into account such factors as service services to be added to the Medical Services Plan.
need, anticipated service volume, health outcomes by the
proposed and alternative services, cost and human resource
requirements, including availability of providers as well as 2.3 Insured Surgical-Dental Services
initial and ongoing competency assurance demands. A regional
health authority initiates the process and, depending on the Dentists may opt out or not participate in the Medical Services
specific service request, it could include consultations involving Plan, but if doing so, they must opt out of all insured surgical-
several branches within the Ministry of Health as well as dental services. The dentist must also advise beneficiaries that
external stakeholder groups such as other regional health the surgical-dental services to be provided are not insured
authorities, service providers and the public. and that the beneficiary is not entitled to reimbursement for
those services. Written acknowledgement from the beneficiary
indicating that he or she understands the advice given by the
2.2 Insured Physician Services dentist is also required. There were no opted-out dentists in
Saskatchewan as of March 31, 2015.
Sections 8 and 9 of the Saskatchewan Medical Care Insurance Act
enable the Minister of Health to establish and administer a plan Insured surgical-dental services are limited to: services in
of medical care insurance for provincial residents. All fee items connection with maxillo-facial surgery required as a result of
for physicians can be found in the Physician Payment Schedule trauma; treatment services for the orthodontic care of cleft palate;
at www.saskatchewan.ca. extraction of teeth when medically required for the provision
of heart surgery, services for chronic renal disease, head and
As of March 31, 2015, there were 2,224 physicians licensed to neck cancer services, and services for total joint replacement
practice in the province and eligible to participate in the Medical by prosthesis when a formal referral has been made and prior
Care Insurance Plan. Of these, 1,181 (53.1 percent) were family approval obtained from Medical Services Branch; and certain
practitioners and 1,043 (46.9 percent) were specialists. services in connection with abnormalities of the mouth and
surrounding structures.
Physicians may opt out or not participate in the Medical
Services Plan, but if doing so, they must fully opt out of all Surgical-dental services can be added to the list of insured
insured physician services. The opted-out physician must also services covered under the Medical Services Plan through a
advise beneficiaries that the physician services to be provided process of discussion and consultation with provincial dental
are not insured and that the beneficiary is not entitled to be surgeons. The Executive Director of the Medical Services
reimbursed for those services. Written acknowledgement from Branch manages the process of adding a new service. Although
the beneficiary indicating that he or she understands the advice formal public consultations are not held, any member of the
given by the physician is also required. public may recommend that surgical-dental services be added
to the Medical Services Plan.
As of March 31, 2015, there were no opted-out physicians
in Saskatchewan. As of March 31, 2015, there were approximately 473 practicing
dentists and dental surgeons located in all major centres in
Insured physician services are those that are medically necessary, Saskatchewan. Seventy-nine provided services insured under
are covered by the Medical Services Plan of the Ministry of the Medical Services Plan.
Health, and are listed in the Physician Payment Schedule of the
Saskatchewan Medical Care Insurance Payment Regulations
(1994) of the Saskatchewan Medical Care Insurance Act.

2.4 Uninsured Hospital, Physician and 3.0 UNIVERSALITY

Uninsured hospital, physician and surgical-dental services 3.1 Eligibility
in Saskatchewan include: in-patient and out-patient hospital
services provided for reasons other than medical necessity; the The Saskatchewan Medical Care Insurance Act (sections 2 and 12)
extra cost of private and semi-private hospital accommodation and the Medical Care Insurance Beneficiary and Administration
not ordered by a physician; physiotherapy and occupational Regulations define eligibility for insured health services in
therapy services not provided by or under contract with a Saskatchewan. Section 11 of the Act requires that all residents
regional health authority; services provided by health facilities register for provincial health coverage.
other than hospitals unless through an agreement with a
regional health authority and licensed under the Health Eligibility is limited to residents. A “resident” means a person
Facilities Licensing Act; non-emergency insured hospital, who is legally entitled to remain in Canada, who makes his
physician or surgical-dental services obtained outside Canada or her home and is ordinarily present in Saskatchewan, or any
without prior written approval; non-medically required other person declared by the Lieutenant Governor-in-Council
elective physician services; surgical-dental services that are to be a resident. Canadian citizens and permanent residents
not medically necessary; and services received under other of Canada relocating from within Canada to Saskatchewan
public programs including the Workers’ Compensation Act, the are generally eligible for coverage on the first day of the third
federal Department of Veteran Affairs and the Mental Health month following establishment of residency in Saskatchewan.
Services Act. Returning Canadian citizens, the families of returning members
As a matter of policy and principle, insured hospital, physician of the Canadian Forces, international students, and international
and surgical-dental services are provided to residents on the basis workers are eligible for coverage on establishing residency in
of assessed clinical need. Compliance is periodically monitored Saskatchewan, provided that residency is established before
through consultation with regional health authorities, physicians the first day of the third month following their admittance
and dentists. There are no charges allowed in Saskatchewan for to Canada.
insured hospital, physician or surgical-dental services. Charges The following persons are not eligible for insured health services
for enhanced medical services or products are permitted only if in Saskatchewan:
the medical service or product is not deemed medically necessary.
Compliance is monitored through consultations with regional ■■ members of the Canadian Forces, federal inmates, refugee
health authorities, physicians and dentists. claimants, visitors to the province; and
Insured hospital services could be de-insured by the government ■■ persons eligible for coverage from their home province
if they were determined to be no longer medically necessary. or territory for the period of their stay in Saskatchewan
The process is based on discussions among regional health (e.g., students and workers covered under temporary
authorities, practitioners, and officials from the Ministry absence provisions from their home province or territory).
of Health.
Such people become eligible for coverage as follows:
Insured physician services could be de-insured if they were
■■ discharged members of the Canadian Forces, if stationed in
determined not to be medically required. The process is based
on consultations with the Saskatchewan Medical Association or resident in Saskatchewan on their discharge date;
and managed by the Executive Director of the Medical ■■ released federal inmates (this includes those prisoners who
Services Branch. have completed their sentences in a federal penitentiary and
those prisoners who have been granted parole and are living
Insured surgical-dental services could be de-insured if they in the community); and
were determined not to be medically necessary. The process is
■■ refugee claimants, on receiving Convention Refugee status
based on discussion and consultation with the dental surgeons
of the province, and is managed by the Executive Director of (immigration documentation is required).
the Medical Services Branch. The number of persons registered for health services in
Formal public consultations about de-insuring hospital, physician Saskatchewan on June 30, 2014, was 1,152,330.
or surgical-dental services may be held if warranted. There were
no services de-insured in 2014–2015.

3.2 Other Categories of Individuals ■■ education: for the duration of studies at a recognized
educational facility (confirmation by the facility of full-time
Other categories of individuals who are eligible for insured student status and expected graduation date are required);
health service coverage include persons allowed to enter ■■ employment of up to 12 months (no documentation
and remain in Canada under authority of a work permit, required); and
study permit or Minister’s permit issued by Citizenship and
Immigration Canada. Their accompanying family may also ■■ vacation and travel of up to 12 months.
be eligible for insured health service coverage.
Saskatchewan has bilateral reciprocal billing agreements with
Refugees are eligible on confirmation of Convention status all provinces for hospital services. Quebec does not participate
combined with a study or work permit, Minister’s permit or in reciprocal billing of physician services.
permanent resident or landed immigrant record.

4.0 PORTABILITY Outside Canada
Section 3 of the Medical Care Insurance Beneficiary and
4.1 Minimum Waiting Period Administration Regulations of the Saskatchewan Medical Care
Insurance Act prescribes the portability of health insurance
In general, insured persons from another province or territory provided to Saskatchewan residents who are temporarily absent
who move to Saskatchewan are eligible on the first day of the from Canada.
third month following establishment of residency. However,
where one spouse arrives in advance of the other, the eligibility Continued coverage for students, temporary workers, vacationers
for the later arriving spouse is established on the earlier of a) and travelers during a period of temporary absence from
the first day of the third month following arrival of the second Canada is conditional on the registrant’s intent to return to
spouse; or b) the first day of the thirteenth month following the Saskatchewan residence immediately on the expiration of the
establishment of residency by the first spouse. approved period as follows:
■■ education: for the duration of studies at a recognized

educational facility (confirmation by the facility of full-time
4.2 Coverage During Temporary Absences student status and expected graduation date are required);
in Canada ■■ contract employment of up to 24 months; and
Section 3 of the Medical Care Insurance Beneficiary and ■■ vacation and travel of up to 12 months.
Administration Regulations of the Saskatchewan Medical Care
Insurance Act prescribes the portability of health insurance Section 3 of the Medical Care Insurance Beneficiary and
provided to Saskatchewan residents while temporarily absent Administration Regulations provides open-ended temporary
within Canada. There were no changes to the in-Canada absence coverage for persons whose principal place of residence
temporary absence provisions in 2014–2015. is in Saskatchewan, but who are not able to satisfy the annual
six months physical presence requirement because the nature
Section 6.6 of the Health Administration Act provides of their employment requires travel from place to place outside
the authority for paying in-patient hospital services to Canada (e.g., cruise line workers).
Saskatchewan beneficiaries temporarily residing outside the
province. Section 10 of the Saskatchewan Medical Care Section 6.6 of the Health Administration Act provides the
Insurance Payment Regulations (1994) provides payment for authority under which a resident is eligible for health coverage
physician services to Saskatchewan beneficiaries temporarily when temporarily outside Canada. In summary, a resident is
residing outside the province. eligible for medically necessary hospital services at the rate of
$100 per in-patient and $50 per out-patient visit per day.
Continued coverage during a period of temporary absence
is conditional upon the registrant’s intent to return to
Saskatchewan residency immediately on expiration of
the approved absence period as follows:

4.4 Prior Approval Requirement In May 2009, the Government of Saskatchewan released
the Physician Recruitment Strategy in an effort to address
Out-of-Province province-wide physician shortages. In 2014–2015 funding
supported several recruitment initiatives:
The Saskatchewan Ministry of Health covers most hospital and
medical out-of-province care received by its residents in Canada ■■ The provincial plan for distributed medical education
through reciprocal billing arrangements. These arrangements continued to be developed and rolled out with the
mean that residents do not need prior approval and may not be goal of increasing the number of medical seats in rural
billed for most services received in other provinces or territories centres. Post-graduate seats were offered in Regina,
while travelling within Canada. The cost of travel, meals and Prince Albert, Swift Current, North Battleford,
accommodation are not covered. La Ronge and Moose Jaw.
■■ The Physician Recruitment Agency of Saskatchewan
Prior approval is required for the following services provided (saskdocs), created in 2009, continued to provide recruit-
out-of-province: ment expertise to communities, physician practices and
■■ alcohol and drug, mental health, rehabilitation,
health agencies.
problem gambling services, home care, and certain ■■ The Saskatchewan International Physician Practice
rehabilitative services. Assessment program worked to ensure that foreign-trained
physicians were assessed with sufficient rigor and patients
Prior approval from the Ministry must be obtained by the received safe, high-quality care.
patient’s specialist.
Other Programs
Out-of-Country
The Family Physician Comprehensive Care Program is
If a specialist physician refers a patient outside Canada for intended to support recruitment and retention of family
treatment not available in Saskatchewan or another province, physicians by recognizing those physicians who provide
the referring specialist must seek prior approval from the a full range of services to their patients and the continuity
Medical Services Plan of the Ministry of Health. The of care that result from these comprehensive services.
Saskatchewan Cancer Agency is consulted for out-of-country
cancer treatment requests. If approved, the Ministry of Health
will pay the full cost of treatment, excluding any items that 5.2 Physician Compensation
would not be covered in Saskatchewan.
Section 6 of the Saskatchewan Medical Care Insurance
Payment Regulations (1994) outlines the obligation of the
5.0 ACCESSIBILITY Minister of Health to make payments for insured services
in accordance with the Physician Payment Schedule and the
Dentist Payment Schedule.
5.1 Access to Insured Health Services
Fee-for-service is the most widely used method of
To ensure that access to insured hospital, physician and surgical- compensating physicians for insured health services in
dental services are not impeded or precluded by financial barriers, Saskatchewan, although sessional payments, salary, and
extra-billing by physicians or dental surgeons, and user charges blended methods are also used. Fee-for-service is the only
by hospitals for insured health services are not allowed in mechanism used to fund dentists for insured surgical-dental
Saskatchewan. services. Total expenditures for in-province physician services
and programs in 2014–2015 amounted to $898.6 million:
Building on the success of the Saskatchewan Surgical Initiative $507.1 million for fee-for-service billings; $30.4 million for
which significantly reduced patient wait times for surgery, Specialist Emergency Coverage Programs; and $361.1 million
the health system is working to strengthen coordination, in non-fee-for-service expenditures. There was also an
communication, and referral guidelines to better coordinate additional $64.3 million for other Saskatchewan Medical
services to ensure patients have timely access to the most Association and bursary programs.
appropriate specialist and diagnostic services. By reducing
the wait time for a consult with a specialist or diagnostic
services (such as MRI and CTs), patients will be able to
access treatment sooner.

5.3 Payments to Hospitals 6.0 RECOGNITION GIVEN TO

Funding to regional health authorities is based on historical FEDERAL TRANSFERS
funding levels adjusted for inflation, collective agreement costs
and utilization increases. Each regional health authority is The Government of Saskatchewan publicly acknowledged the
given a global budget and is responsible for allocating funds federal contributions provided through the Canada Health
within that budget to address service needs and priorities Transfer in the Ministry’s 2014–2015 Annual Report, the
identified through its needs assessment processes. Government of Saskatchewan 2014–2015 Budget and related
documents, its 2014–2015 Public Accounts, and the Quarterly
Regional health authorities may receive additional funds for and Mid-Year Financial Reports. These documents were
providing specialized hospital programs (e.g., renal dialysis, tabled in the Legislative Assembly and are publicly available to
specialized medical imaging services, specialized respiratory Saskatchewan residents. Federal contributions have also been
services, and surgical services), or for providing services to acknowledged on the Ministry of Health website, in news
residents from other health regions. releases and issue papers, and in speeches and remarks made
at various conferences, meetings and public policy forums.
Payments to regional health authorities for delivering services are
made pursuant to section 8 of the Regional Health Services Act.
The legislation provides the authority for the Minister of Health
to make grants to regional health authorities and health care
organizations for the purposes of the Act, and to arrange for
providing services in any area of Saskatchewan if it is in the
public interest to do so.
Regional health authorities provide an annual report on the

aggregate financial results of their operations.

REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
1. Number as of March 31st (#). 1,070,477 1,084,127 1,090,953 1,121,755 1,152,330 1

2. Number (#). 66 66 66 66 66
3. Payments for insured health services ($). 1,636,013,000 2

1,694,858,000 2
1,777,208,000 2
1,846,795,000 2
1,889,855,000 2


for insured health services ($). Not Available 3
Not Available 3
Not Available 3
Not Available 3
Not Available 3

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
7. Total payments, in-patient ($). 48,700,300 51,418,800 54,483,700 53,004,700 42,834,000 4

11. Total payments, in-patient ($). 3,401,000 8,186,600 5

2,007,000 2,271,900 4,529,900
13. Total payments, out-patient ($). 1,796,700 3,203,800 1,511,300 1,606,100 480,300 6
1. Saskatchewan’s numbers as of June 30, 2014.

2. This number includes estimated government funding to regional health authorities in their annual audited financial statements.
– Includes acute care services, specialized hospital services, and in-hospital specialist services.
– Does not include inpatient mental mental health, or addiction treatment services.
– Does not include payments to Saskatchewan Cancer Agency for out-patient chemotherapy and radiation.
3. Private facilities providing surgical services and computed tomography scans receive payments for these services under contract with regional health authorities.
The Ministry of Health does not provide payments to these facilities.
4. Decrease in 2014–15 due to decrease in in-patient claims and corresponding mix of procedure cost.
5. Increase in 2011–12 was due to a cluster of high cost procedures Saskatchewan residents received in the United States.
6. Decrease in 2014–15 was due to a decrease in out-of-country treatments.


2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

methods ($). 714,441,498 794,901,943 823,656,225 873,484,838 898,584,963

physicians paid through fee-for-service ($). 457,194,531 7
457,307,474 7
480,173,762 7
488,651,587 7
507,079,008 7

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 31,505,813 32,103,002 33,658,928 35,703,160 37,220,270

21. Number of services (#). not available not available not available not available not available
22. Total payments ($). 1,324,100 2,279,100 1,199,100 1,484,200 1,416,300

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
25. Total payments ($). 1,827,088 1,719,770 1,710,397 1,669,803 1,870,512
7. Figure is composed of fee-for-service billing and funding for the Emergency Rural Coverage Program which is paid through the fee-for-service program.

ALBERTA
INTRODUCTION Goal 2: Albertans have improved health as a result of

protecting and promoting wellness and supporting
independence
Alberta’s Health Care System
Over 1.2 million Albertans received the influenza vaccine in
The Minister of Health, the Department of Health (Alberta 2014–2015. This is 30 percent of the population, as compared
Health) and the Regional Health Authority (Alberta Health to 27 percent in 2013–2014. Pharmacists administered
Services) play key roles in Alberta’s health care system. All 486,709 doses of influenza vaccine and Alberta Health
entities work together to deliver better care, improve health Services Public Health administered 492,220 doses.
outcomes and provide the best health care system possible Reports show that 64 percent of Alberta Health Services
for Albertans. health care workers were immunized in the 2014–2015
influenza season, as compared to 60 percent in 2013–2014.
The vision of Alberta Health; Healthy Albertans in a Healthy
Alberta, is achieved through a commitment to the mission, core The Skin Cancer Prevention (Artificial Tanning) Act is a major
business and goals of the ministry. Alberta Health’s mission step forward in the effort to reduce cancer in Alberta. The bill
is to set policy and direction to improve health outcomes for for this Act was passed in March 2015. When the legislation
all Albertans, support the wellbeing and independence of is proclaimed in force and regulations completed, it will:
Albertans, and achieve a high quality, appropriate, accountable
and sustainable health system. Alberta Health’s core business ■■ ban businesses from selling and providing artificial tanning
is improving Albertans’ health status over time. services to minors;
■■ prohibit advertising of artificial tanning directed to minors;
Over the past year Alberta has made progress towards three key
desired outcomes: ■■ mandate health warnings in artificial tanning facilities and
on advertising materials; and
Goal 1: Strengthened health system leadership, ■■ prohibit unsupervised, self-serve artificial tanning equipment
in public places.
accountability and performance
Each year approximately 1,600 medical residents train through Goal 3: Albertans have enhanced access to high
Alberta’s two medical schools and over 300 undergraduate quality, appropriate, cost-effective health care
medical students commence their medical studies. Medical
and support services
residents provide direct clinical services during their two to
eight years of training. Approximately 70 percent of Alberta’s The government is committed to providing the support needed
medical graduates set up practice in Alberta, which is the to improve evolving primary care delivery that responds to the
second highest retention rate in Canada. health care needs of Albertans. Alberta’s Primary Health Care
Strategy, released in May 2014, sets the direction for Primary
Health Care transformation and reinforces the vision for
Albertans to be as healthy as they can be.

CHAPTER 3: ALBERTA
1.0 PUBLIC ADMINISTRATION The publicly funded services provided by approved hospitals in
Alberta range from the most advanced levels of diagnostic and
treatment services for in-patients and out-patients, to routine
care and management of patients with previously diagnosed
1.1 Health Care Insurance Plan and chronic conditions. The benefits available to hospital patients
Public Authority in Alberta are established in the Hospitalization Benefits
Regulation (AR 244/1990). The Regulation is available at:
Alberta Health administers and operates the Alberta Health www.health.alberta.ca/about/health-legislation.html.
Care Insurance Plan in accordance with the Canada Health Act.
Since 1969, the Alberta Health Care Insurance Act has governed There is no regular process to review insured hospital services,
the operation of the Alberta Health Care Insurance Plan. as the list of insured services included in the regulations is
The Minister of Health, working in conjunction with the intended to be both comprehensive and generic, and does
appropriate stakeholders, determines which services are covered not require routine review and updating. Changes to specific
by the Alberta Health Care Insurance Plan. physician services can be found in the Schedule of Medical
Benefits, and are described in the next section.

2.2 Insured Physician Services
The Minister of Health is accountable for the Alberta Health
Care Insurance Plan. The Fiscal Management Act, which came The Alberta Health Care Insurance Act governs the payment of
into force in 2013, provides a framework to govern budgeting physicians for insured physician services under the Alberta
and fiscal planning. Health Care Insurance Plan (section 6). Only physicians who
meet the requirements stated in the Act are permitted to make
a claim for payment of benefits for providing insured services
1.3 Audit of Accounts under the Alberta Health Care Insurance Plan.
The Auditor General of Alberta audits all government Alberta had 8,873 physicians participating under the Alberta
ministries, departments, regulated funds and provincial Health Care Insurance Plan as of March 31, 2015. Within this,
agencies, and is responsible for assuring the public that the 7,405 physicians were paid exclusively under fee-for-service,
government’s financial reporting is credible. The Auditor 697 were compensated solely under an Alternative Relationship
General of Alberta completed an audit of Alberta Health on Plan (ARP) and the remaining 771 physicians received
June 5, 2015 and indicated that the statements fairly represent, compensation from both fee-for-service and ARP. Out of the
in all material respects, the financial position and results of 4,537 General Practitioners, 3,284 were registered providers
operations for the year that ended March 31, 2015. in Primary Care Networks as of March 31, 2015.
Before being registered with the Alberta Health Care Insurance

2.0 COMPREHENSIVENESS Plan, a physician must complete the appropriate registration
forms and include a copy of his or her license issued by the
College of Physicians and Surgeons of Alberta.
2.1 Insured Hospital Services Under section 8 of the Alberta Health Care Insurance Act, all
In Alberta, Alberta Health Services is the body responsible to physicians are deemed to be opted into the Alberta Health
the Minister of Health for ensuring the provision of insured Care Insurance Plan. A physician may; however, opt out by
hospital services. The Hospitals Act, the Hospitalization notifying the Minister they wish to opt out of the Alberta
Benefits Regulation (AR 244/1990), the Health Care Health Care Insurance Plan. Under section 8(2) a physician
Protection Act, and the Health Care Protection Regulation may opt out of the Plan by (a) notifying the Minister in writing
(AR 208/2000) govern the provision of insured services indicating the effective date of the opting out, (b) publishing
by hospitals or designated non-hospital surgical facilities. a notice of the proposed opting out in a newspaper having
A directory of approved hospitals in Alberta can be found at: general circulation in the area in which the physician practices,
www.health.alberta.ca/services/health-benefits-services.html. and (c) posting a notice of the proposed opting out in a part
of the physician’s office to which patients have access at least
During 2014–2015, no amendments were made to the legislation 180 days prior to the effective date of the opting out. By opting
regarding insured hospital services. out of the Alberta Health Care Insurance Plan, a physician
agrees that, commencing on the opt-out effective date, they
will not participate in the publicly funded health system.

CHAPTER 3: ALBERTA
This means that the physician cannot make a claim from the seek reimbursement for any amounts paid by the patient for
Alberta Health Care Insurance Plan for payment for providing receiving surgical-dental services from the opted-out dentist.
what would otherwise be publicly funded health services and As of March 31, 2015, no dentists were opted-out of the
the patient cannot seek reimbursement for any amounts paid Alberta Health Care Insurance Plan.
by the patient for receiving health services from the opted-out
physician. As of July 1, 2014, one physician opted out of the
Alberta Health Care Insurance Plan in the province. 2.4 Uninsured Hospital, Physician, and
Section 12 of the Alberta Health Care Insurance Regulation Surgical-Dental Services
lists services which are not considered as basic or extended Section 12 of the Alberta Health Care Insurance Regulation
health services. The Medical Benefits Regulation establishes lists services which are not considered as basic or extended
the benefits payable for insured medical services provided to a health services. Section 4(2) of the Hospitalization Benefits
resident of Alberta. Descriptions of those services are set out Regulation provides a list of hospital services that are not
in the Schedule of Medical Benefits, which can be accessed at: considered to be insured.
www.health.alberta.ca/professionals/SOMB.html.
The Preferred Accommodation and Non Standard Goods
or Services Policy describes the Government of Alberta’s
2.3 Insured Surgical-Dental Services expectations of Alberta Health Services and guides the
provision of preferred accommodation, and enhanced or non-
In Alberta, a small number of surgical-dental services are standard goods and services. This policy framework requires
insured. The majority of dental procedures that can be billed to Alberta Health Services to provide 30 days advance notice to
the Alberta Health Care Insurance Plan can only be performed the Health Minister’s designate regarding the categories of
by a dentist certified as an oral and maxillofacial surgeon preferred accommodation offered and the charges associated
who meets the requirements stated in the Alberta Health Care with each category. Alberta Health Services is also required
Insurance Act. to provide 30 days advance notice to the Health Minister’s
Alberta insures a number of medically necessary oral surgical designate regarding any goods or services that will be provided
and dental procedures that are listed in the Schedule of Oral as non-standard goods or services. Alberta Health Services
and Maxillofacial Surgery Benefits, available at: www.health. must also provide information about the associated charge
alberta.ca/professionals/allied-services-schedule.html. for these goods or services, and when applicable, the criteria
or clinical indications that may qualify patients to receive it
Although there is no formal agreement with dentists, Alberta as a standard good or service. Alberta’s policy for Preferred
Health meets with members of the Alberta Dental Association Accommodation and Non-Standard Goods or Services is
and College to discuss changes to the Schedule of Oral and available at: www.health.alberta.ca/documents/preferred-
Maxillofacial Surgery Benefits. All changes to the benefit accommodation-policy-2005.pdf.
schedule require Ministerial approval.
Under section 7 of the Alberta Health Care Insurance Act, all 3.0 UNIVERSALITY
dentists are deemed to have opted into the Plan. A dentist may
opt out by notifying the Minister of Health they wish to opt
out of the Alberta Health Care Insurance Plan. 3.1 Eligibility
Under section 7(2) a dentist may opt out of the Plan by Under the terms of the Alberta Health Care Insurance Act,
(a) notifying the Minister in writing indicating the effective Alberta residents are eligible to receive publicly funded health
date of the opting out, (b) publishing a notice of the proposed care services under the Alberta Health Care Insurance Plan.
opting out in a newspaper having general circulation in the A resident is defined as a person lawfully entitled to be or to
area in which the dentist practices, and (c) posting a notice remain in Canada, who makes the province his or her home and
of the proposed opting out in a part of the dentist’s office to is ordinarily present in Alberta as defined in the regulations.
which patients have access at least 30 days prior to the effective The term “resident” does not include a tourist, transient, or
date of the opting out. By opting out of the Alberta Health visitor to Alberta. Persons moving permanently to Alberta from
Care Insurance Plan, a dentist agrees that, commencing on outside Canada are eligible for coverage if they have permanent
the opt-out effective date, they will not participate in the resident status, are returning landed immigrants, or are returning
publicly funded health system. This means that the dentist Canadian citizens. Persons in Alberta on an approved Canada
cannot make a claim from the Alberta Health Care Insurance entry permit may also be eligible for coverage under the Alberta
Plan for payment for providing what would otherwise be Health Care Insurance Plan, and their eligibility is reviewed on
publicly funded surgical-dental services and the patient cannot a case-by-case basis.

CHAPTER 3: ALBERTA
Certain categories of individuals who would otherwise be

considered residents are deemed by the Alberta Health Care
4.0 PORTABILITY
Insurance Act to be eligible for coverage received under federal
legislation. These residents who are not eligible for coverage
under the Alberta Health Care Insurance Plan, but receive
health care coverage from the federal government, include: Under the Alberta Health Care Insurance Plan, generally
persons moving permanently to Alberta from another part of
■■ members of the Canadian Armed Forces; and
Canada are eligible for coverage on the first day of the third
■■ persons serving a term in a federal penitentiary. month following their arrival.
Spouses or partners and dependents of the above are provided

with Alberta Health Care Insurance Plan coverage if they are 4.2 Coverage During Temporary Absences
Alberta residents.
in Canada
The Alberta Health Care Insurance Plan will cover individuals
released from the Canadian Armed Forces, and federal The Alberta Health Care Insurance Plan provides coverage
penitentiaries, effective the date of release, if notified within for eligible Alberta residents who temporarily leave Alberta
three months. If they are released in another part of Canada, for other parts of Canada. A person is considered temporarily
they are eligible for coverage on the first day of the third absent from Alberta if the person stays in another province or
month after becoming a resident of Alberta. The RCMP Health territory for a period that will not exceed 12 consecutive months.
Coverage Statutes Amendment Act provides Royal Canadian
Individuals who are routinely absent from Alberta every
Mounted Police members coverage under the Alberta Health
year normally must spend a cumulative total of 183 days in a
Care Insurance Plan.
12 month period in Alberta to maintain continuous coverage.
In order to access insured services under the Alberta Health Individuals not present in Alberta for the required 183 days
Care Insurance Plan, Alberta residents are required to register may be considered residents of Alberta if they satisfy Alberta
themselves and their eligible dependents. Family members are Health of their permanent and principal place of residence
registered on the same account. Persons moving to Alberta within the province. Individuals may also remain eligible
should apply for coverage within three months of arrival or for coverage if, on a recurring basis, they are absent from
effective dates may be affected. For persons moving to Alberta Alberta for up to 212 days in 12 month period for the purpose
from within Canada, their registration is effective on the first of vacation.
day of the third month after their arrival. For persons moving
Alberta participates in the interprovincial hospital and medical
to Alberta from outside Canada, their registration is effective
reciprocal billing agreements. All provinces and territories
the day they become an Alberta resident. The Alberta Health
except Quebec participate in medical reciprocal agreements.
Care Insurance Plan process, for registering Albertans and
These agreements were established to minimize complex billing
issuing replacement health cards, requires registrants to provide
processes and to help ensure timely payments to physicians
documentation that proves their identity, legal entitlement
and hospitals when they provide services to residents from
to be in Canada, and Alberta residency.
other provinces or territories. Under these agreements, where
As of March 31, 2015, there were 4,354,660 Alberta residents an eligible Albertan receives an insured physician service or
registered with the Alberta Health Care Insurance Plan. Under hospital service in another participating province or territory,
the Health Insurance Premiums Act, a resident may opt out of Alberta will reimburse for the insured service provided at the
the Alberta Health Care Insurance Plan by filing a declaration host province’s or territory’s rates for that insured service.
with the Minister of Health. As of March 31, 2015, there were
In 2014–2015, no amendments were made to the legislation
249 Alberta residents who were opted out of the Plan.
regarding portability in Canada. More information on coverage
during temporary absences outside Alberta is available at:
www.health.alberta.ca/AHCIP/outside-coverage.html.
3.2 Other Categories of Individuals
Section 16 of the Hospitalization Benefits Regulation addresses
Certain categories of individuals with an approved Canada
payment for hospital services obtained outside of Alberta but
entry permit may also be eligible for coverage. These
within Canada. Section 4 of the Medical Benefits Regulation
include individuals with Student or Employment Permits,
addresses payment of physician services obtained outside of
Temporary Resident Permits, and Visitor Records. There
Alberta but within Canada. These sections were not amended
were 104,335 people covered under these conditions as of
in 2014–2015.
March 31, 2015.

CHAPTER 3: ALBERTA
4.3 Coverage During Temporary Absences 4.4 Prior Approval Requirement

Outside Canada Prior approval is not required for elective insured services
The Alberta Health Care Insurance Plan provides coverage received in another Canadian province or territory, except for
to eligible Alberta residents who are temporarily absent from high-cost items not included in reciprocal agreements such as
Canada. A person is considered to be temporarily absent from gamma knife surgery.
Alberta if the person stays outside Canada for a period that will Prior application is required for elective services received
not exceed six consecutive months, and the person intends to out-of-country and approval may only be given through the
return to and maintain permanent residence in Alberta on the Out-of-Country Health Services Committee for insured
conclusion of their stay outside Alberta. services that are medically required, are not experimental,
Individuals who are routinely absent from Alberta every and are not available in Alberta or elsewhere in Canada.
year normally must spend a cumulative total of 183 days in a
12 month period in Alberta to maintain continuous coverage.
Individuals not present in Alberta for the required 183 days 5.0 ACCESSIBILITY
may be considered residents of Alberta if they satisfy Alberta
Health of their permanent and principal place of residence
within the province. Individuals may also remain eligible 5.1 Access to Insured Health Services
for coverage if, on a recurring basis, they are absent from
The Ministries of Health and Infrastructure have the
Alberta for up to 212 days in 12 month period for the purpose
responsibilities for planning and management of the Health
of vacation.
Facilities Capital Program and projects. The Ministry of Health
Individuals leaving the province temporarily on extended is responsible for setting strategic directions and implementing
vacations, or for temporary employment, may be eligible health policy, legislation, standards and providing the global
for coverage for 24 to 48 consecutive months. They should operating funding to Alberta Health Services (AHS) for
contact Alberta Health to enquire about their coverage. Students the provision of provincial health services. Alberta Health
attending an accredited educational institute on a full-time basis Services identifies and prioritizes health service needs requiring
are entitled to coverage for the duration of their studies. capital development. The Government of Alberta supports
health infrastructure by funding capital development and
The maximum amount payable for out-of-country in-patient the infrastructure maintenance program. The Ministry of
hospital services is $100 (Canadian) per day (not including Infrastructure is responsible for the design, construction
day of discharge). The maximum hospital out-patient visit rate and delivery of major health capital projects throughout the
is $50 (Canadian), with a limit of one visit per day. The only province. The Ministry of Infrastructure is currently leading
exception is haemodialysis received as an out-patient, which major health capital projects in High Prairie, Grande Prairie,
until March 31, 2015, was paid at a maximum of $423 per Edson, Edmonton, Calgary, Red Deer, Medicine Hat,
visit, with a limit of one visit per day. Effective April 1, 2015, Taber, Lethbridge and Raymond. Health legislation also
the rate increased from $423 to $453 per visit. Physician and stipulates the requirements for the purchase and disposition
dental specialist/oral surgeon services are paid according to of assets and properties and the general provisions for health
Alberta rates. Funding may also be available through the infrastructure. More information on capital plans is available
Out-of-Country Health Services Committee process that will at: http://finance.alberta.ca/publications/budget/budget2015-
evaluate reimbursement requests made by Alberta physicians october/fiscal-plan-capital-plan.pdf.
or dentists for eligible Alberta residents for medically necessary
services covered under the Alberta Health Care Insurance
Plan, and received in an emergency situation or that were 5.2 Physician Compensation
not available in Canada. More information on coverage
during temporary absences outside Canada is accessible at: The Alberta Health Care Insurance Act governs the payment of
www.health.alberta.ca/AHCIP/outside-coverage.html. physicians. Physicians are compensated through the Alberta
Health Care Insurance Plan on a volume-driven, fee-for-service
Section 16 of the Hospitalization Benefits Regulation addresses basis or through the use of Alternative Relationship Plans
payment for hospital services obtained outside of Canada. (ARPs). ARPs are used by specialists and family physicians
Section 5 of the Medical Benefits Regulation addresses and offer alternative compensation models to the fee-for-service
payment of physician services obtained outside Canada. payment system. The goal of ARPs is to contribute to better
These sections were not amended in 2014–2015. health outcomes by supporting innovative health care delivery.

CHAPTER 3: ALBERTA
The purpose of ARPs is to enhance physician recruitment and According to the Health Care Protection Act, Ministerial
retention, team-based approaches to service delivery, access approval for a service agreement shall not be given unless:
to services, patient satisfaction, and value for money. ARPs
provide predictable funding that enables physician groups ■■ the insured surgical services are consistent with the principles
to recruit new physicians to their programs and retain their of the Canada Health Act;
services while in some cases additional funding is provided ■■ there is a current and likely future need for the services
to support this service delivery approach. ARPs are unique in the geographical area;
in that they offer an alternative funding model to the way
■■ the proposed surgical services will not have an adverse
government has traditionally funded health care service
impact on the province’s publicly funded and publicly
delivery by physicians.
administered health system;
Alberta Health and the Alberta Medical Association entered ■■ there will be an expected benefit to the public;
into the Alberta Medical Association Agreement (AMAA)
■■ AHS has an acceptable business plan to pay for the services;
in 2013, which was retroactive to April 1, 2011. The financial
terms of the AMAA establish set increases to the insured ■■ the proposed agreement contains performance expectations
services rates for seven years (from 2011 to 2018), and Alberta and measures; and
Health and the Alberta Medical Association will negotiate new ■■ the physicians providing the services will comply with
financial terms for April 1, 2018 onwards. the conflict of interest and ethical requirements of the
Health Professions Act and the bylaws of the College of
The Ministry also funds Primary Care Networks (PCNs) in
Physicians and Surgeons of Alberta.
which family physicians work with AHS to improve access to
primary care and increase the availability of multi‑disciplinary Pursuant to the terms of any agreement as between AHS and a
teams and chronic disease management. PCNs receive per‑capita facility operator, AHS agrees to pay a contracted “facility fee.”
payments in order to enhance or add services, including funding This fee covers such costs as some staff salaries and benefits,
other health care providers and offering programs. Each PCN supplies, utilities, and other overhead costs. Physicians
decides how funds will be allocated based on alignment with who provide insured surgical services to patients within an
PCN policy and approved business plans. accredited NHSF are paid on a fee-for-service basis through
the Alberta Health Care Insurance Plan. These fees are the
same regardless of whether the physician provides the insured
5.3 Payments to Hospitals service in a public hospital setting or in a NHSF.
The Regional Health Authorities Act governs the funding
of Alberta’s single regional health authority; AHS. The
provision of insured health services by AHS is funded 6.0 RECOGNITION GIVEN TO
through a single base operating grant. Funding is provided
for insured services delivered in hospitals and designated
FEDERAL TRANSFERS
non-hospital surgical facilities. The Government of Alberta publicly acknowledged the federal
contributions provided through the Canada Health Transfer in
Alberta’s Health Care Protection Act governs the provision of its 2014–2015 publications.
insured and uninsured surgical services performed in public
hospitals and in Non-Hospital Surgical Facilities (NHSFs.).
Ministerial approval of a service agreement between the facility
operator and AHS is required in order for the facility to provide
insured surgical services. Ministerial designation of a NHSF
and accreditation by the College of Physicians and Surgeons
of Alberta is also required.

CHAPTER 3: ALBERTA
REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

2. Number (#). 225 225 226 225 225

providing insured health services (#). not available not available not available not available not available

for insured health services ($). not available not available not available not available not available
INSURED HOSPITAL SERVICES PROVIDED TO RESIDENTS IN ANOTHER PROVINCE OR TERRITORY 1

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
INSURED HOSPITAL SERVICES PROVIDED OUTSIDE CANADA1,2

1. Data reported for indicators 6 through 13 reflect claims processed up to three months after the close of the fiscal year. Any claims processed after this date are
not reflected in the presented information.
2. These data do not include claims/payments for Alberta residents who have received health services through the Out-of-Country Health Services Committee
application process.

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

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
14. Number of participating physicians (#). 4 6,743 7,706 8,100 8,466 8,873 5
15. Number of opted-out physicians (#). not applicable 6

0 6
0 6
0 6
0 6



2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 25,340,583 27,960,901 27,940,698 30,710,409 32,203,224
INSURED PHYSICIAN SERVICES PROVIDED OUTSIDE CANADA 7

21. Number of services (#). 15,654 42,643 8
39,317 8
33,804 8
not available 9
22. Total payments ($). 909,715 2,573,169 8

2,435,305 8
2,189,233 8
not available 9

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
25. Total payments ($). 5,747,026 6,293,750 7,077,327 7,317,869 8,208,000
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.
4. Starting in 2011–2012, and going forward, the physician count includes physicians who are fee-for-service, in Alternative Relationship Plans or receive compensation
from both fee-for-service and Alternative Relationship Plans. Prior year reflected physicians that were only paid under fee-for-service.
5 7,405 of these are paid under fee-for-service, 697 under an Alternative Relationship Plan and the remaining 771 received compensation from both fee-for-service
and alternative relationship plans.
6 Alberta’s legislation provides that all physicians are deemed to be participating in the Alberta Health Care Insurance Plan, unless they opt out in accordance with
the procedure set out in section 8 of the Alberta Health Care Insurance Act.
7 These data do not include Alberta residents who have received health services through the Out-of-Country Health Services Committee application process.
8 The 2011–2012 to 2013–2014 figures are calculated using a new methodology for capturing the out-of-country claim process. The change now includes a one year
lag from the fiscal year end to date of payment for more precise data.
9 Data for out of country physician services are still being processed for 2014–2015.

BRITISH COLUMBIA
INTRODUCTION The purpose of the MPA is to preserve a publicly-managed

and fiscally sustainable healthcare system for British Columbia,
British Columbia has a progressive and integrated health in which access to necessary medical care is based on need
system that includes insured services funded under the and not on an individual’s ability to pay.
Canada Health Act, services funded wholly or partially by
The Medical Services Commission (MSC) manages MSP on
the Government of British Columbia and services regulated,
behalf of the Government of British Columbia in accordance
but not funded, by government. The Ministry of Health
with the MPA (section 3) and its Regulation. The function and
(the Ministry) has overall responsibility for ensuring that
mandate of the MSC is to facilitate reasonable access to quality
quality, appropriate, and timely health services are available
medical care, healthcare, and diagnostic facility services for
to all British Columbians.
British Columbians.
To read more about British Columbia’s publicly funded health
The MSC is a nine-member statutory body made up of three
system, please refer to the Ministry of Health 2015/16 —
representatives from the Government of British Columbia,
2017/18 Service Plan:
three representatives from Doctors of BC (formerly the
http://bcbudget.gov.bc.ca/2015/sp/pdf/ministry/hlth.pdf British Columbia Medical Association), and three members
from the public jointly nominated by Doctors of BC
and government.
1.0 PUBLIC ADMINISTRATION General hospital services are insured in British Columbia;
however, this is not covered by MSP. General hospital services
are provided under the Hospital Insurance Act (section 8)
1.1 Health Care Insurance Plan and and its Regulation; the Hospital Act (section 4); and the
Public Authority Hospital District Act (section 20).
The Ministry sets goals, standards, and performance

agreements for provincial health service delivery and works 1.2 Reporting Relationship
with the province’s six health authorities to provide quality,
appropriate, and timely health services to British Columbians. The Ministry provides information in the Annual Service
Five regional health authorities deliver a full continuum of Plan Report on the performance of British Columbia’s
health services to meet the needs of the population within publicly funded health system. Tracking and reporting this
their respective geographic regions. A sixth health authority, information is consistent with the Ministry’s strategic approach
the Provincial Health Services Authority, is responsible to performance planning and reporting and is consistent with
for managing the quality, coordination, and accessibility of requirements contained in the provincial Budget Transparency
province-wide health programs and services. The Ministry and Accountability Act (2000).
also works in partnership with the First Nations Health
Authority to improve the health status of First Nations The MSC is accountable to the Government of British Columbia
in British Columbia. through the Minister of Health (the Minister); a report is
published annually for the prior fiscal year which provides
Most insured services are covered by the British Columbia an annual accounting of the business of the MSC, its
Medical Services Plan (MSP), which is administered by the subcommittees, and other delegated bodies. This report
Ministry. MSP covers medically required services provided is available at: www2.gov.bc.ca/gov/content/health/
by physicians and supplementary healthcare practitioners, practitioner-professional-resources/msp/publications
laboratory services, and diagnostic procedures. The Medicare
Protection Act (MPA) is the enabling legislation for MSP.

CHAPTER 3: BRITISH COLUMBIA
1.3 Audit of Accounts RSBC is required to comply with all applicable laws,
including the:
The Ministry is subject to audit of accounts and financial
transactions through: ■■ Ombudsman Act;
■■ Business Practices and Consumer Protection Act; and
■■ Internal Audit and Advisory Services (IAAS); the
government’s internal auditor. IAAS determines the scope ■■ Financial Administration Act.
of the internal audits and timing of the audits. IAAS ■■ Freedom of Information Legislation (i.e., Freedom of
reports can be located on the following website link: Information and Protection of Privacy Act, including
www.fin.gov.bc.ca/ocg/ias/Audit_Reports.htm FOIPPA Inspections; the Personal Information Protection
■■ The Office of the Auditor General (OAG) of British Columbia Act and the equivalent federal legislation, if applicable).
is responsible for conducting annual audits as well as special
audits and reports. The OAG reports its findings to the
Legislative Assembly. The OAG initiates its own audits 2.0 COMPREHENSIVENESS
and determines the scope of its audits. The Select Standing
Committee on Public Accounts of the Legislative Assembly
reviews the recommendations of the OAG. 2.1 Insured Hospital Services
The OAG’s annual audit of the Ministry’s accounts and The Hospital Act and Hospital Act Regulation provide
financial transactions are reflected in the OAG’s overall review authority for the Minister to designate facilities as hospitals,
and opinion related to the BC Public Accounts, which can to license private residential care hospitals, to approve the
be found at the following website link: www.fin.gov.bc.ca/ bylaws of hospitals, to inspect hospitals, and to appoint a
ocg/pa/14_15/Public%20Accounts%2014-2015.pdf public administrator. This legislation also establishes broad
parameters for the operation of hospitals.
The OAG’s special audits and reports can be located at the
following link: www.bcauditor.com/pubs The Hospital Insurance Act and the Hospital Insurance Act
Regulations provide the authority for the Minister to make
payments to health authorities for the purpose of operating
1.4 Designated Agency hospitals, outlines who is entitled to receive insured services,
and defines the “general hospital services” which are to be
Since 2005, the Ministry has contracted with MAXIMUS provided as benefits.
Canada to deliver the operations of MSP and PharmaCare
(including responding to public inquiries, registering clients, Hospital services are insured when they are provided to a
and processing medical and pharmaceutical claims from health beneficiary in a publicly funded hospital, and are deemed
professionals). MAXIMUS Canada administers the province’s medically required by the attending physician, midwife, nurse
medical and drug insurance plans under the Health Insurance practitioner, or oral and maxillofacial surgeon. There is no
BC (HIBC) program. Policy and decision-making functions scheduled or regular process to review insured hospital services
remain with the Ministry. as the insured services included in the regulations are intended
to be inclusive. Uninsured services are referred to in section 2.4
HIBC submits monthly reports to the Ministry, reporting of this report.
performance on service levels to the public and healthcare
providers. HIBC also posts reports on its website on When medically required, the following are provided
the performance of key service levels. These reports to beneficiaries who are in-patients in an acute or
are available at: www2.gov.bc.ca/gov/content/health/ rehabilitation hospital:
about-bc-s-health-care-system/partners/health-insurance-bc
■■ accommodation and meals at the standard level;
HIBC processes payments against fee items approved by the ■■ necessary nursing service;
Ministry. The Ministry approves all payments before they
are released. ■■ drugs, biologicals, and related preparations which are
required by the patient and administered in hospital;
MSP requires premiums to be paid by eligible residents. ■■ laboratory and radiological procedures and related
Revenue Services of British Columbia (RSBC) performs interpretations;
revenue management services, including account management,
billing, remittance, and collection on behalf of the Province ■■ diagnostic procedures and the necessary interpretations,
of British Columbia (Ministry of Finance). The province as approved by the Minister;
remains responsible for and retains control of all government
administered collection actions.

■■ use of operating rooms, caserooms, anaesthetic facilities, Unless specifically excluded, the following medical services are
routine surgical supplies, and other necessary equipment insured as MSP benefits under the MPA in accordance with the
and supplies; Canada Health Act:
■■ use of radiotherapy facilities; ■■ medically required services provided to beneficiaries
■■ use of physiotherapy facilities; (residents of British Columbia who are enrolled in MSP
■■ services of a social worker; in accordance with section 7 of the MPA) by a physician
enrolled with MSP; and
■■ other rehabilitation services, including occupational and
■■ medically required services performed in an approved
speech therapy; and
diagnostic facility under the supervision of an enrolled
■■ other required services approved by the Minister, provided physician.
by persons who receive remuneration from the hospital.
To practice in British Columbia, physicians must be registered
When medically required, the following are provided as and in good standing with the College of Physicians and
benefits under the Hospital Insurance Act or the Medicare Surgeons of British Columbia. To receive payment for
Protection Act (MPA) to out-patients who are beneficiaries: insured services, they must be enrolled with MSP. In the
fiscal year 2014–2015, 10,411 physicians were enrolled with
■■ emergency department services;
MSP and received payments through fee-for-service (FFS).
■■ diagnostic services (e.g., laboratory or radiological In addition, some physicians practice solely on salary, receive
procedures); sessional payments, or are on contract (service agreements)
■■ use of operating room facilities; with the health authorities. Physicians paid by these alternative
mechanisms may also practice on a FFS basis.
■■ equipment and supplies used in medically necessary services
provided to the beneficiary, including anaesthetics, sterile Practitioners other than physicians and dentists who may enroll
supplies, dressings, casts, splints, immobilizers, and bandages; and provide benefits under MSP include midwives, optometrists
■■ meals required during diagnosis and treatment; and supplementary benefit practitioners. The Supplementary
Benefits Program assists premium assistance beneficiaries
■■ drugs and medications administered in a medically necessary (see section 3.3 of this report) to access the following services:
service provided to the beneficiary; and acupuncture, massage therapy, physiotherapy, chiropractic,
■■ any service provided by an employee of the hospital that naturopathy, and podiatry (non-surgical services). The program
is approved by the Minister. contributes $23.00 towards the cost of each patient visit to a
maximum of ten visits per patient per annum summed across
The services are provided to beneficiaries without charge, with the six types of providers.
a few exceptions. Exceptions include: incremental charges for
preferred (but not medically required) medical/surgical supplies Physicians enrolled in MSP may choose to be opted-in
and nonstandard accommodation (when not medically required or opted-out. Opted-in physicians are physicians who are
and standard accommodation is available), and daily fees for enrolled in MSP under section 13 of the MPA and who
residential care patients in extended care or general hospitals. elect to bill MSP directly for insured services provided to
MSP beneficiaries. An opted-in physician may not bill a
Some facilities providing residential care services (in this case, patient directly for an insured benefit. Opted-out physicians
the term “extended care” is often used) are regulated under are physicians who are enrolled in MSP under section 13
the Hospital Act. Health authorities and hospital societies are of the MPA and who elect to opt out and bill patients
required to follow Home and Community Care policies to directly for insured benefits. Physicians wishing to opt out
determine benefits in such cases. of MSP must give written notice to the Medical Services
Commission (MSC). In this case, patients may apply to MSP
for reimbursement of the fee for insured services rendered.
2.2 Insured Physician Services By law, an opted-out physician may not charge a patient more
for an insured benefit than the prescribed MSP amount.
The range of insured physician services covered by the In 2014–2015, MSP had two opted-out physicians. Based
Medical Services Plan (MSP) includes all medically on reclassification of information and corresponding data,
necessary diagnostic and treatment services. Insured British Columbia does not track non-participating physicians.
physician services are provided under the MPA. Section
13 provides that practitioners, including physicians and Under the Physician Master Agreement between the government,
healthcare professionals such as midwives, who are enrolled the MSC and Doctors of BC, modifications to the Payment
with MSP and who render benefits to a beneficiary, are Schedule such as additions, deletions or fee changes are
eligible to be paid for services rendered in accordance made by the MSC upon advice from Doctors of BC or the
with the appropriate payment schedule. government. To modify the payment schedule, parties must

submit proposals to the Doctors of BC Tariff Committee. Procedures not insured under the Hospital Insurance Act and
On recommendation of the Tariff Committee, interim listings its regulations include: services of medical personnel not
may be designated by the MSC for new procedures or other employed or contracted by the hospital; treatment for which
services for a limited period of time while definitive listings WorkSafeBC, the Department of Veterans Affairs or any other
are established. agency is responsible; services or treatment that the Minister
(or a person designated by the Minister) determines, on a review
During fiscal year 2014–2015, 37 physician services were added of the medical evidence, that the beneficiary does not require;
as MSP insured benefits to reflect current practice standards and excluded illnesses or conditions (i.e. in vitro fertilization,
including, for example, the introduction of peritonectomy cosmetic service solely for the alteration of appearance; and
with or without chemotherapy. reversal of previous sterilization procedures except when
sterilization was originally caused by trauma). Uninsured
hospital services also include: preferred accommodation at
2.3 Insured Surgical-Dental Services the patient’s request when not medically required; preferred
medical/surgical supplies/devices; televisions, telephones, and
In certain circumstances, in-patient or out-patient hospitalization
private nursing services; and dental care that could safely be
is medically required for the safe and proper completion of
provided in a dental office including prosthetic and orthodontic
surgical-dental services. In such cases, the surgical-dental
services. Health authorities are required by Ministry policy
component is covered if the service is listed in the Dental
to fund medically necessary transfers between acute care
Payment Schedule and the hospitalization component is
hospitals within British Columbia, but patients are required
funded by the health authority.
to pay a user fee to partially offset costs when an ambulance or
Included as insured surgical-dental procedures are those related to contracted alternative service provider is used for transport in
remedying a disorder of the oral cavity or a functional component other situations.
of mastication. Generally this would include oral surgery related
Services not insured under MSP include: those covered by
to trauma, orthognathic surgery, medically required extractions,
the Workers’ Compensation Act or by other federal or provincial
and surgical treatment of temporomandibular joint dysfunction.
legislation; provision of non-implanted prostheses; orthotic
Additions or changes to the list of insured services are managed
devices; proprietary or patent medicines; any medical
by MSP on the advice of the Dental Liaison Committee.
examinations that are not medically required; oral surgery
Additions and changes must be approved by the MSC.
rendered in a dentist’s office; telephone advice unrelated
Any general dental and/or oral surgeon who is in good standing to insured visits; reversal of sterilization procedures;
with the College of Dental Surgeons, is enrolled in MSP, and in vitro fertilization; medico-legal services; and most
has hospital privileges, may provide insured surgical-dental cosmetic surgeries.
services in hospital. There were 214 dentists enrolled with MSP
The MPA (section 45) prohibits the sale or issuance of health
in 2014–2015 (includes only paediatric dentists, oral surgeons,
insurance by private insurers to patients for services that would
dental surgeons, oral medicine, and orthodontist billing
be an insured benefit. Section 17 prohibits persons from being
through FFS).
charged for a benefit or for “materials, consultations, procedures,
and use of an office, clinic or other place or for any other matters
that relate to the rendering of a benefit.”
2.4 Uninsured Hospital, Physician and
Surgical-Dental Services The Ministry responds to complaints made by patients and
takes appropriate actions to correct situations identified to the
Medical necessity, as determined by the attending physician, Ministry. The MSC determines which services are benefits
midwife, nurse practitioner, or oral and maxillofacial surgeon and has the authority to de-insure insured services. Proposals
and hospital, is the criterion for public funding of available to de-insure services must be made to the MSC. Consultation
hospital and medical services. may take place through a sub-committee of the MSC and
usually includes a review by Doctors of BC’s Tariff Committee.
In-patient and out-patient take-home drugs and any In 2013-2014, nine fee items from the Section of Laboratory
drugs not clinically approved by the hospital are excluded Medicine were removed from the Fee Schedule; each of the
from coverage. items was related to drugs of abuse testing and was found to
be redundant or obsolete.

3.0 UNIVERSALITY 3.2 Other Categories of Individuals

Some holders of Minister’s Permits, Temporary Resident
Permits, study permits, work permits and applicants for
3.1 Eligibility permanent resident status who are the spouse or child of
Section 7 of the Medicare Protection Act (MPA) defines the an eligible resident may be eligible for benefits when deemed
eligibility and enrolment of beneficiaries for insured services. to be residents under the MPA and section 2 of the Medical
Under the MPA, Part 2 of the Medical and Health Care and Health Care Services Regulation.
Services Regulation details residency requirements. A person
must be a resident of British Columbia to qualify for provincial
healthcare benefits. 3.3 Premiums
Section 1 of the MPA defines a resident as a person who: The enabling legislation is:
■■ is a citizen of Canada or is lawfully admitted to Canada ■■ Medicare Protection Act, Part 2 — Beneficiaries section 8; and
for permanent residence; ■■ Medical and Health Care Services Regulation,
■■ makes his or her home in British Columbia, and is physically Part 3 — Premiums.
present in British Columbia for at least six months in a
Enrolment in MSP is mandatory and payment of premiums
calendar year, or for a prescribed shorter period of time; and
is ordinarily a requirement for coverage. However, failure to
■■ is deemed under the regulations to be a resident pay premiums is not a barrier to coverage for those who meet
(does not include a tourist or visitor to British Columbia). the basic enrolment eligibility criteria. Monthly premiums
for MSP since January 1, 2015, are $72.00 for one person,
Certain other individuals, such as some holders of $130.50 for a family of two, and $144.00 for a family of
permits issued under the federal Immigration and Refugee three or more.
Protection Act are deemed to be residents (see section 3.2 of
this report), but this does not include a tourist or visitor to MSP has two programs that offer assistance with the
British Columbia. payment of premiums based on financial need. Regular
premium assistance has five levels of assistance and is
In 2014–2015, the Medical and Health Care Services based on a person’s net income for the preceding tax year,
Regulation was amended to clarify the terms upon which a combined with that of the person’s spouse, if applicable,
resident of British Columbia may be absent from the province less MSP deductions. In 2014–2015, amendments to Part 3
due to vacation or work and remain a beneficiary who of the Medical and Health Care Services Regulation
qualifies for healthcare benefits. changed provisions specifying the calculation of income
for determining eligibility for premium assistance. New
New residents or persons re-establishing residence in
provisions address the application of premium assistance for
British Columbia must be physically present in British Columbia
beneficiaries “in care” at institutions designated as hospitals
for at least six months prior to being absent for more than
or nursing homes licensed as private hospitals, and those
six months. If absences exceed six months prior to the individual
in receipt of long-term care at a licensed community care
being physically present for at least six months, residence is not
facility, and for beneficiaries whose spouse is in care.
established and medical coverage is canceled as of the initial
enrolment date. A short term, 100 percent subsidy is offered under the
temporary premium assistance program based on current,
All residents are entitled to hospital and medical care
unexpected financial hardship. Premium assistance is available
insurance coverage. Those residents who are members of the
only to beneficiaries who, for the last 12 consecutive months,
Canadian Forces and those serving a term of imprisonment
have resided in Canada and are either a Canadian citizen or a
in a penitentiary as defined in the Penitentiary Act, are
holder of permanent resident (landed immigrant) status under
eligible for federally funded health insurance. The Medical
the federal Immigration and Refugee Protection Act.
Services Plan (MSP) provides first-day coverage to discharged
members of the Canadian Forces and to those returning from
an overseas tour of duty, as well as to released inmates of
federal penitentiaries.
The number of residents registered with MSP as of

March 31, 2015 was 4,672,899.

4.0 PORTABILITY which services were rendered. For in-patient hospital care,
services are paid at the ward rate approved for each hospital by
the Assistant Deputy Ministers Policy Advisory Committee.
For out-patient services, the payment is at the inter-provincial/
4.1 Minimum Waiting Period territorial reciprocal billing rate. Payment for these services,
New residents or persons re-establishing residence in except for excluded services that are billed to the patient,
British Columbia are eligible for coverage after completing is handled through inter-provincial/territorial reciprocal
a waiting period that normally consists of the balance of the billing procedures.
month residence is established plus two additional months.
Quebec does not participate in reciprocal billing agreements
For example, if an eligible person arrives during the month of
for physician services. As a result, claims for services provided
July, coverage is available October 1. If absences from Canada
to British Columbia beneficiaries by Quebec physicians must
exceed a total of 30 days during the waiting period, eligibility
be handled individually. When travelling in Quebec (or outside
for coverage may be affected. New residents from other parts
of Canada) the beneficiary is usually required to pay for medical
of Canada are advised to maintain coverage with their former
services and seek reimbursement later from MSP.
medical plan during the waiting period.
British Columbia pays host provincial rates for insured services
according to rates established by the Interprovincial Health
4.2 Coverage During Temporary Absences Insurance Agreements Coordinating Committee.
in Canada
Sections 3, 4 and 5 of the Medical and Health Care Services 4.3 Coverage During Temporary Absences
Regulation define portability provisions for persons temporarily
absent from British Columbia with regard to insured services.
Outside Canada
The legislation that defines portability of health insurance
Residents who spend part of every year outside British Columbia
during temporary absences outside Canada is stated in the
must be physically present in Canada at least six months in a
Hospital Insurance Act, section 24; the Hospital Insurance
calendar year and continue to maintain their home in British
Act Regulations, Division 6; the Medicare Protection Act,
Columbia in order to retain coverage. As of January 1, 2013,
section 51; and the Medical and Health Care Service
longer term vacationers who are deemed residents may qualify
Regulation, sections 3, 4, and 5.
for a total absence of up to seven months per calendar year for
vacation purposes only, provided they continue to maintain their Residents who leave British Columbia temporarily to attend school
home in British Columbia. or university are eligible for MSP coverage for the duration of their
studies provided they were physically present in Canada for six of
Individuals leaving the province temporarily on extended
the 12 months immediately preceding departure, and are in full-
vacations, or for temporary employment, may be eligible
time attendance at a recognized educational facility. Beneficiaries
to retain their medical coverage for up to 24 consecutive
who have been studying outside British Columbia must return
months provided that they are physically present in BC
to the province by the end of the month following the month in
for six of the 12 months immediately preceding departure.
which studies are completed. Any student who will not return to
Approval is limited to once in five years for absences exceeding
British Columbia within that timeframe should contact MSP.
six months in a calendar year. When a beneficiary stays outside
British Columbia longer than the approved period, they will Residents who spend part of every year outside British Columbia
be required to fulfill a waiting period upon re-establishing must be physically present in Canada at least six months
residence in the province before coverage can be renewed. in a calendar year and continue to maintain their home
Students attending a recognized school in another province in British Columbia in order to retain coverage. As of
or territory on a full-time basis are entitled to coverage for January 1, 2013, longer term vacationers who are deemed
the duration of their studies, provided that they return to BC residents may qualify for a total absence of up to seven months
permanently by the last day of the month following the month per calendar year for vacation purposes.
in which their studies end.
In some circumstances, while temporarily outside the province for
According to inter-provincial/territorial reciprocal billing work or vacation, an individual may be deemed an eligible resident
arrangements, physicians, except in Quebec, bill their own during an ‘extended absence’ of up to 24 consecutive months
medical plans directly for services rendered to British Columbia once in a five-year period. To qualify, he or she must continue to
residents who are eligible for the Medical Services Plan (MSP), maintain their home in British Columbia, be physically present in
upon presentation of a valid CareCard or BC Services Card. Canada for six of the 12 months immediately preceding departure
British Columbia then reimburses the province or territory and have not been granted an extended absence in the previous five
at the rate of the fee schedule in the province or territory in calendar years. In addition, they must not have taken advantage of

the additional one month absence available to vacationers during services in not-for-profit residential facilities) may require the
the year the extended absence begins, or during the calendar year recommendation of the Ministry of Health.
prior to the start of the extended absence. In certain situations,
if a person’s employment requires them to routinely travel outside All non-emergency procedures performed outside Canada
of British Columbia for more than six months per calendar year, require approval from the MSC before the procedure.
they can apply to the Medical Services Commission (MSC) for
approval to maintain their eligibility.
5.0 ACCESSIBILITY
British Columbia residents who are temporarily absent from
British Columbia and cannot return due to extenuating health
circumstances may be deemed residents for up to an additional 5.1 Access to Insured Health Services
12 months if they are visiting in Canada or abroad. This also
applies to the person’s spouse and children provided they are Beneficiaries in British Columbia, as defined in section 1 of
with the person and they are also residents or deemed residents. the Medicare Protection Act (MPA), are eligible for all insured
hospital and medical care services as required. To ensure equal
British Columbia residents who are eligible for coverage access to all, regardless of income, the MPA, sections 17 and
while temporarily absent from British Columbia may receive 18, prohibits extra-billing by enrolled practitioners.
reimbursement from MSP for out-of-country medical expenses.
MSP provides coverage for out-of-country emergency physician Access to insured services continues to be enhanced:
services up to the B.C. physician fee rates. Reimbursement
for out-of-country emergency hospital services is limited to ■■ The Alternative Payments Program funds regional health
a maximum benefit of $75.00 per day. Any excess cost is the authorities to contract with or hire general practitioners
responsibility of the beneficiary. All reimbursement is made (GPs) and/or specialists in order to deliver insured
in Canadian dollars. clinical services.
■■ The Full-Service Family Practice Incentive Program
continues to be expanded as the Ministry of Health
4.4 Prior Approval Requirement (the Ministry) and physicians continue to work together
to develop incentives aimed at helping to support and
No prior approval is required for medically required procedures sustain full-service family practice.
that are covered under interprovincial reciprocal agreements with
other provinces. Prior approval from the MSC is required for ■■ The Ministry provides funding through the Medical
procedures that are excluded under the reciprocal agreements. On-Call Availability Program to health authorities
to enable them to contract with groups of physicians
The physician services excluded under the Interprovincial to provide “on-call” coverage necessary for hospitals
Agreements for the Reciprocal Processing of Out-of-Province to deliver emergency healthcare services to unassigned
Medical Claims are: surgery for alteration of appearance patients in a reliable, effective, and efficient manner.
(cosmetic surgery); gender reassignment surgery; surgery ■■ The Ministry continued and implemented several
for reversal of sterilization; routine periodic health programs under the 2012 Rural Practice Subsidiary
examinations including routine eye examinations; in vitro Agreement, which were continued in the Physician
fertilization, artificial insemination; acupuncture, acupressure, Master Agreement (PMA) to enhance the availability
transcutaneous electro-nerve stimulation, moxibustion, and stability of physician services in smaller urban,
biofeedback, hypnotherapy; services to persons covered by rural, and remote areas of British Columbia.
other agencies (e.g., Canadian Armed Forces, Workers’ An outline of these programs can be obtained at:
Compensation Board, Department of Veterans Affairs, www.health.gov.bc.ca/pcb/rural.html
Correctional Services of Canada); services requested by a
third party; team conferences; genetic screening and other Infrastructure and Capital Planning
genetic investigation, including DNA probes; procedures still
in the experimental/developmental phase; and anaesthetic British Columbia continues to make strategic investments
services and surgical assistant services associated with all of in health sector capital infrastructure. The Ministry invests
the foregoing. annually to renew and extend the asset life of existing health
facilities, medical and diagnostic equipment, and information
The services on this list may or may not be reimbursed by management technology at numerous health facilities across
the home province. The patient should make inquiries of British Columbia. The Ministry has developed a ten-year
that home province either before receiving treatment by a capital plan to ensure health infrastructure is maintained
British Columbia physician or after direct payment to the and renewed within expected asset lifecycle timelines.
British Columbia physician. Some treatments (e.g., treatment

5.2 Physician Compensation Compensation Methods for Physicians and Dentists
The PMA is a formal agreement signed by the Government Payment for medical services delivered in the province is made
of British Columbia, BC Medical Association (the Doctors through MSP to individual physicians, based on submitted
of BC), and the Medical Services Commission (MSC). In claims, and through the Alternative Payment Program to
December 2014, doctors in British Columbia voted in favour of health authorities for physician time spent providing services
a new agreement with government. The new five-year agreement to patients. The government funds health authorities to enter
(term April 1, 2014 to March 31, 2019) supports ongoing efforts into alternative payment arrangements with other physicians;
to recruit and retain physicians while also improving access to it does not pay physicians directly. In British Columbia, MSP
specialists and care in rural and remote communities. only pays for medically required dental services and medically
required dental surgical services performed in a hospital.
The PMA gives the Doctors of BC exclusive right to represent
the interests of all physicians who receive payment for the
medical services they provide to persons insured through MSP. 5.3 Payments to Hospitals
The PMA establishes mechanisms which promote enhanced
collaboration and accountabilities between the province and Funding for insured hospital services are included within
Doctors of BC through various joint committees. It also annual funding allocations to health authorities, as well as
provides a formal conflict management process at both the local specifically targeted funding from time to time. This funding
and provincial levels and language limiting physician service allocation is used to fund the full range of necessary health
withdrawals. The role of health authorities in the planning and services for the population of the region (or for specific
delivery of healthcare services are reinforced in the PMA. provincial services, for the population of British Columbia),
including the provision of hospital services. Annual funding
The PMA establishes the compensation and benefit structure allocations to health authorities are determined as part of the
for physicians who provide publicly funded medical services Ministry’s annual budget process in consultation with the
whether on fee-for-service or alternate funding methods Ministry of Finance and Treasury Board. The final funding
(service contracts, salaries, and sessional arrangements). amount is conveyed to health authorities by means of an annual
Through the PMA, the province also provides targeted funding letter.
financial support for areas such as: rural physician incentive
programs; access to specialist services; supporting full service The Hospital Insurance Act and its related regulations and the
family practices; and shared care models involving GPs, Health Authorities Act govern payments made by government
specialists, and other healthcare professions. to health authorities. These statutes establish the authority of
the Minister of Health to make payments to regional health
Physicians are licensed under the Health Professions Act, with authorities, the Provincial Health Services Authority and the
their Payment Schedule established under section 26 of the Nisga’a Nation; and specifies in broad terms what services are
MPA. The agreement provides processes for monitoring and insured when provided within a hospital and in delivering
managing the funding established by the MSC under section regional healthcare services.
25 of the MPA for insured medical services provided by
physicians on a fee-for-service basis. Mechanisms for revisions The British Columbia Tripartite Framework Agreement
to the Payment Schedule and for the payment of physicians on First Nation Health Governance and other negotiated
are detailed in the PMA. agreements, provide the basis for the Ministry of Health
to provide funding to the First Nations Health Authority.
Dentists are licensed under the Health Professions Act.
The province and the British Columbia Dental Association The Ministry does not specifically fund hospitals directly;
(BCDA) have entered into a Dentistry Master Agreement for instead health authorities are funded and provide operating
the period April 1, 2014 to March 31, 2019 that covers the budgets to hospitals within their control to deliver specified
following services: dental surgery; oral surgery; orthodontic services. The exception to this is when funding provided to
services; oral medicine; pediatric dental services; and dental health authorities (again not directly to hospitals) is targeted
technical procedures. Both the province and the BCDA meet for specific priority projects (e.g., reduction in wait times for
through a Dentistry Liaison Committee for the duration of specific procedures). Since it is specifically targeted, it must
the agreement. be reported on separately.

Incremental funding is allocated to health authorities using

the Ministry’s Population Needs-Based Funding Formula and
other funding allocation methodologies (e.g., to reflect targeted FEDERAL TRANSFERS
funding allocations directed to specific health authorities). The
annual funding allocation to health authorities does not include Funding provided by the federal government through the
funding for programs directly operated by the Ministry, such as Canada Health Transfer is recognized and reported by the
payments to physicians through the Medical Services Plan and Government of British Columbia through various government
payments for prescription drugs covered under PharmaCare. websites and provincial government documents. In 2014–2015,
In 2014–2015, the Ministry continued to examine alternative these documents included:
funding methodologies including the use of pay-for-performance
and activity-based funding. ■■ Estimates, Fiscal Year Ending March 31, 2015, available at:
http://bcbudget.gov.bc.ca/2014/estimates/2014_Estimates.pdf
The accountability mechanisms associated with government ■■ Budget and Fiscal Plan 2014–2015 to 2016–2017, available at:
funding for hospitals is part of several comprehensive documents http://bcbudget.gov.bc.ca/2014/bfp/2014_budget_and_
which set expectations for health authorities. These are the fiscal_plan.pdf
annual funding letter, annual service plans, and annual
Government Letters of Expectations. Taken together, these ■■ Public Accounts 2014–2015, available at:
documents convey the Ministry’s broad expectations for health http://www.fin.gov.bc.ca/ocg/pa/14_15/Public%20
authorities and explain how performance will be monitored in Accounts%2014-15.pdf
relation to these expectations.

REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

2. Number (#).1 119 120 120 120 121
3. Payments for insured health services ($). 2 not available not available not available not available not available

providing insured health services (#). not available not available not available not available not available

for insured health services ($). not available not available not available not available not available

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

13. Total payments, out-patient ($). 999,733 1,301,179 1,646,810 2,098,735 1,599,213
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.


2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
14. Number of participating physicians (#). 3 9,417 9,628 9,947 10,119 10,411
16. Number of not participating physicians (#). not available not available not available not available not available



2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 30,698,752 32,453,109 32,502,933 33,860,748 37,002,462

22. Total payments ($). 4,240,090 4,869,497 4,340,034 4,148,174 4,091,804

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
25. Total payments ($). 7,991,262 8,130,009 7,903,742 8,456,773 8,417,735
3. The number of participating physicians in item 14 is for physicians who received payments through fee-for-service.

YUKON
INTRODUCTION In 2014–2015, Insured Health and Hearing Services (IHS)

contracted with a Nurse Practitioner to open a Women’s
The Yukon Health Care System is committed to ensuring that Midlife Health Clinic and a Reproductive Health Clinic.
residents of the Yukon acquire the skills to live responsible, IHS also hired a Nurse Practitioner to work at the Referred
healthy and independent lives. The Minister of Health and Care Clinic in Whitehorse in September 2014.
Social Services is responsible for delivering all insured health
care services with service delivery administered centrally
by the Department of Health and Social Services (DHSS). 1.0 PUBLIC ADMINISTRATION
The overall objective of the DHSS is to ensure access to, and
portability of, insured physician and hospital services according
to the provisions of the Health Care Insurance Plan Act and the 1.1 Health Care Insurance Plan and
Hospital Insurance Services Act. Public Authority
Additionally, extended health benefits provided to eligible The Government of Yukon delivers insured health benefits
Yukon residents include the Travel for Medical Treatment according to the Yukon Health Care Insurance Plan (YHCIP)
Program; the Children’s Drug and Optical Program; the and the Yukon Hospital Insurance Services Plan (YHISP).
Chronic Disease and Disability Benefits Program; and the Both the YHCIP and YHISP are administered by the Director,
Pharmacare and Extended Benefits Programs. Other health Insured Health and Hearing Services. This position is a joint
service programs administered by DHSS include Community appointment by the Minister of Health and Social Services and
Health; Community Nursing; Continuing Care; and Mental the Commissioner of the Yukon Territory.
Health Services. Currently, most communities in Yukon
contain Community Health Centres, where residents have The Health Care Insurance Plan Act, section 3(2) and section 4,
access to a team of health care professionals with diverse skills. establishes the public authority to operate the health care plan.
There were no amendments made to these sections of the Act
The Yukon Hospital Corporation operates the three hospitals in 2014–2015.
in the territory: Whitehorse General Hospital, Watson
Lake Community Hospital and Dawson City Community The Hospital Insurance Services Act, section 3(1) and section 5,
Hospital. In January 2015, a temporary facility at the establishes the public authority to operate the hospital care
Whitehorse General Hospital (WGH) opened which houses plan. There were no amendments made to these sections of
Canada’s first magnetic resonance imaging (MRI) program the Act in 2014–2015.
north of 60. In addition, in 2014–2015 construction was started
at WGH to expand the Emergency Department and provide Subject to the Health Care Insurance Plan Act (section 5), the
expansion of the Radiology Department along with providing Hospital Insurance Services Act (section 6) and the regulations,
a permanent location for the MRI program. it is the responsibility of the Director, Insured Health and
Hearing Services to:
The Yukon Government continues to utilize teleradiology and
telehealth services to improve health care services for Yukoners ■■ administer both plans;
living in more rural communities. Further, Nurse Practitioner ■■ determine eligibility for insured health services;
(NP) legislation that was enacted in December 2012, has
■■ establish advisory committees and appoint individuals
allowed the Yukon Registered Nurses Association to license
five NPs in Yukon to expand health care options for patients, to advise or assist in the operation of the plans;
and improve the quality and access of collaborative primary ■■ determine the amounts payable for insured health services
care. Currently there are four NPs delivering services outside the Yukon;
in Whitehorse. ■■ conduct surveys and research programs, and obtain statistics
for such purposes;

CHAPTER 3: YUKON
■■ appoint inspectors and auditors to examine and obtain related to the Department of Health and Social Services
information from medical records, reports, and accounts; and released in 2014–2015.
■■ perform any other functions and discharge any other duties Further, section 13(2) of the Hospital Act requires the Yukon
assigned by the Minister of Health and Social Services Hospital Corporation to submit a report of their operations
under the Act. for that fiscal year to the Minister within six months after the
Specific to the Hospital Insurance Services Act, the Director, end of each fiscal year. The report is to include the financial
Insured Health and Hearing Services has the responsibility to: statements of the Corporation and the Auditor’s report.
■■ enter into agreements on behalf of the Government of

Yukon with hospitals in or outside of Yukon, or with the 2.0 COMPREHENSIVENESS
Government of Canada or any province or an appropriate
agency thereof, for the provision of insured services to
insured persons; 2.1 Insured Hospital Services
■■ prescribe the forms and records necessary to carry out the The Hospital Insurance Services Act, sections 3, 4, 5, 6 and 9,
provisions of the Act; and establish authority to provide insured hospital services to
■■ perform any other functions and discharge any other duties insured residents. The Yukon Hospital Insurance Services
assigned to the administrator by the Regulations. Ordinance was first passed in 1960 and came into effect
April 9, 1960. No amendments were made to the Act
There were no amendments to either Act in 2014–2015. in 2014–2015.
Adopted on December 7, 1989, the Hospital Act establishes

1.2 Reporting Relationship the responsibility of the legislature and the government
to ensure “compliance with appropriate methods of
The Department of Health and Social Services is accountable operation and standards of facilities and care.” Adopted
to the Legislative Assembly and the Government of Yukon on November 11, 1994, the annexed Hospital Standards
through the Minister. Regulation sets out the conditions under which all hospitals
in the territory are to operate. Section 4(1) provides for the
Section 6 of the Health Care Insurance Plan Act and section 7 Ministerial appointment of one or more investigators to
of the Hospital Insurance Services Act require that the Director, report on the management and administration of a hospital.
Insured Health and Hearing Services make an annual report Section 4(2) requires that the hospital’s Board of Trustees
to the Minister of Health and Social Services respecting the establish and maintain a quality assurance program.
administration of the two health insurance plans. A Statement
of Revenue and Expenditures is tabled in the legislature and In April 1997, the Yukon Government assumed responsibility
is subject to discussion at that level. The Statement of Revenue for operating health centres in rural Yukon communities from
and Expenditures will be tabled in the fall 2015 sitting of the the federal government. These facilities operate in compliance
Yukon legislature. with the adopted Medical Services Branch Scope of Practice for
Community Health Nurses, Nursing Station Facility, Health
Centre Treatment Facility and the Community Health Nurse
1.3 Audit of Accounts Scope of Practice. The General Duty Nurse Scope of Practice
was completed and implemented in February 2002.
The Health Care Insurance Plan and the Hospital Insurance
Services Plan are subject to audit by the Office of the Auditor In 2014–2015, insured in-patient and out-patient hospital
General of Canada. The Auditor General of Canada is the services were delivered in 14 facilities throughout the territory.
Auditor of the Government of Yukon in accordance with These facilities include Whitehorse General Hospital, Watson
section 34 of the Yukon Act (Canada). The Auditor General is Lake Community Hospital, Dawson City Community
required to conduct an annual audit of the transactions and Hospital and 11 primary health care centres.
consolidated financial statements of the Government of Yukon.
Further, the Auditor General of Canada is to report to the The Yukon Hospital Corporation completed their accreditation
Yukon Legislative Assembly any matter falling within the scope process in May 2014 as part of a four-year cycle through
of the audit that, in his or her opinion, should be reported to Accreditation Canada. Whitehorse General Hospital and
the Assembly. Watson Lake Community Hospital took part in this process,
while Dawson City Community Hospital will take part in the
In 2013, the Office of the Auditor General of Canada released next process in 2018.
the 2013 Report of the Auditor General of Canada, Capital
Projects — Yukon Hospital Corporation. There were no reports

CHAPTER 3: YUKON
Pursuant to the Hospital Insurance Services Regulations, Hospital also began construction on a permanent location for
section 2(e) and (f), services provided in an approved hospital the MRI along with an expansion of the Emergency Room
are insured. Section 2(e) defines in-patient insured services Department in 2014–2015.
as all of the following services to in-patients, namely:
accommodation and meals at the standard or public ward These measures will help reduce Yukon’s reliance on out-of-
level; necessary nursing service; laboratory, radiological and territory services.
other diagnostic procedures together with the necessary
interpretations for the purpose of maintaining health,
preventing disease and assisting in the diagnosis and treatment 2.2 Insured Physician Services
of an injury, illness or disability; drugs, biologicals and related
Insured physician services in Yukon are defined as medically
preparations as provided in Schedule B of the Regulations,
required services rendered by a medical practitioner. Sections 1
when administered in the hospital; use of operating room, case
to 8 of the Health Care Insurance Plan Act and sections 2, 3, 7, 10
room and anaesthetic facilities, including necessary equipment
and 13 of the Health Care Insurance Plan Regulations provide
and supplies; routine surgical supplies; use of radiotherapy
for insured physician services. No amendments were made to
facilities where available; use of physiotherapy facilities
the Act in 2014–2015.
where available; and services rendered by persons who receive
remuneration therefor from the hospital. The Yukon Health Care Insurance Plan covers physicians
providing medically required services. In order to participate
Section 2(f) of the regulations defines “out-patient insured
in the Yukon Health Care Insurance Plan, physicians must:
services” as all of the following services to out-patients, when
used for emergency diagnosis or treatment within 24 hours ■■ register for licensure pursuant to the Health Professions Act; and
of an accident (period may be extended by the Administrator,
provided the service could not be obtained within 24 hours of ■■ maintain licensure, pursuant to the Health Professions Act.
the accident): necessary nursing service; laboratory, radiological
The number of resident physicians participating in the Yukon
and other procedures, together with the necessary interpretations
Health Care Insurance Plan in 2014–2015 was 70, along with
for the purpose of assisting in the diagnosis and treatment of an
36 locums and 45 visiting specialists.
injury; drugs, biologicals and related preparations as provided in
Schedule B, when administered in a hospital; use of operating Section 7 of the Yukon Health Care Insurance Plan Regulations
room and anaesthetic facilities, including necessary equipment covers payment for medical services. Subsection 4 allows
and supplies; routine surgical supplies; services rendered by physicians to make arrangements for payment for insured
persons who receive remuneration therefor from the hospital; services on a basis other than fee-for-service. Notice in writing
use of radiotherapy facilities where available; and use of of this election must be submitted to the Director, Insured
physiotherapy facilities where available. Health and Hearing Services. In 2014–2015, there were
physicians both on fee-for-service and alternate payment
Pursuant to the Hospital Insurance Services Regulations,
arrangements for remuneration.
all in-patient and out-patient services provided in an approved
hospital, by hospital employees, are insured services. The process used to add a new fee to the Payment Schedule
Standard nursing care, pharmaceuticals, supplies, diagnostic for Yukon is administered through a committee structure.
and operating services are provided. Any new programs This process requires physicians to submit requests in
or enhancements with significant funding implications or writing to the Yukon Health Care Insurance Plan, Yukon
reductions to services or programs require the prior approval Medical Association Liaison Committee. Following review
of the Minister, Health and Social Services. This process by this committee, a decision is made to include or exclude
is managed by the Director, Insured Health and Hearing the service. The relevant costs or fees are normally set in
Services. Public representation regarding changes in service accordance with similar costs or fees in other jurisdictions.
levels is made through membership on the hospital board. Once a fee-for-service value has been determined, notification
of the service and the applicable fee is provided to all Yukon
Yukon remains committed to the administration of the Weight
physicians. Public consultation is not required.
Wise program in Whitehorse. In previous years, clients were
sent to Alberta to participate in the program. With the help Alternatively, new fees can be implemented as a result of the fee
of Alberta Health Services, a local physician and a local negotiation process between the Yukon Medical Association
registered nurse have been trained in delivering the program and the Department of Health and Social Services. The
in-territory. The first intake of clients began in the fall of 2010. Director, Insured Health and Hearing Services manages this
The Whitehorse General Hospital opened the first MRI in process and no public consultation is required.
northern Canada on January 13, 2015. Whitehorse General

CHAPTER 3: YUKON
2.3 Insured Surgical-Dental Services bill by service item. Billable services include but are not limited
to: completion of employment forms; medical-legal reports;
Dentists providing insured surgical-dental services under the transferring records; third-party examinations; some elective
health care insurance plan of Yukon must be licensed pursuant services; and telephone prescriptions, advice or counseling.
to the Dental Professions Act and are given billing numbers
to bill the Yukon Health Care Insurance Plan for providing Payment does not affect patient access to services because not
insured dental services. The Plan is also billed directly for all physicians or clinics bill for these services and other agencies
services provided outside the territory. or employers may cover the cost.
Insured dental services are limited to those surgical-dental Uninsured dental services include procedures considered
procedures listed in Schedule B of the Health Care Insurance restorative and procedures that are not performed in a hospital
Plan Regulations. The procedures must be performed in under general anesthesia.
a hospital.
All Yukon residents have equal access to services. Third parties,
The addition or deletion of new surgical-dental services to the such as private insurers or the Worker’s Compensation Health
list of insured services requires amendment by Order-in-Council and Safety Board, do not receive priority access to services
to Schedule B of the Health Care Insurance Plan Regulations. through additional payment. The purchase of non-insured
Coverage decisions are made on the basis of whether or not the services, such as fiberglass casts, does not delay or prevent
service must be provided in hospital under general anaesthesia. access to insured services at any time. Insured persons are given
The Director, Insured Health and Hearing Services administers treatment options at the time of service.
this process.
Yukon has no formal process to monitor compliance; however,
There were no new insured surgical-dental services added in feedback from physicians, hospital administrators, medical
2014–2015. professionals and staff allows the Director, Insured Health and
Hearing Services to monitor usage and service concerns.
The process used to de-insure services covered by the Yukon

2.4 Uninsured Hospital, Physician and Health Insurance Plan is as follows:
Physician services — the Yukon Health Care Insurance
Only services prescribed by and rendered in accordance with Plan, Yukon Medical Association Fee Liaison Committee is
the Health Care Insurance Plan Act and Regulations and the responsible for reviewing changes to the Payment Schedule
Hospital Insurance Services Act and Regulations are insured. for Yukon including decisions to de-insure certain services.
All other services are uninsured. In consultation with the Yukon Medical Advisor, decisions
to de-insure services are based on medical evidence that
Uninsured hospital services include: non-resident hospital indicates the service is not medically necessary, is ineffective
stays; special or private nurses requested by the patient or or a potential risk to the patient’s health. Once a decision has
family; additional charges for preferred accommodation unless been made to de-insure a service, all physicians are notified in
prescribed by a physician; crutches and other such appliances; writing. The Director, Insured Health and Hearing Services,
nursing home charges; televisions; telephones; and drugs and manages this process. No services were removed in 2014–2015.
biologicals following discharge. (These services are not provided
by the hospital). Hospital services — an amendment by Order-in-Council
to sections 2(e) and 2(f) of the Yukon Hospital Insurance
Section 3 of the Yukon Health Care Insurance Plan Regulations Services Regulations would be required. As of March 31, 2015,
contains a list of services that are prescribed as non-insured. no insured in-patient or out-patient hospital services, as
Uninsured physician services include: advice by telephone; provided for in the Regulations, have been de-insured. The
medical-legal services; testimony in court; preparation of Director, Insured Health and Hearing Services is responsible
records, reports, certificates and communications; services or for managing this process in conjunction with the Yukon
examinations required by a third party; services, examinations Hospital Corporation.
or reports for reasons of attending university or camp;
examination or immunization for the purpose of travel, Surgical-dental services — an amendment by Order-in-
employment or emigration; cosmetic services; services not Council to Schedule B of the Health Care Insurance Plan
medically required; giving or writing prescriptions; the supply Regulations is required. A service could be de-insured if
of drugs; dental care except procedures listed in Schedule B; determined not medically necessary or is no longer required
and experimental procedures. to be carried out in a hospital under general anaesthesia.
The Director, Insured Health and Hearing Services manages
Physicians in Yukon may bill patients directly for non-insured this process. No surgical-dental services were de-insured
services. Block fees are not used at this time; however, some do in 2014–2015.

CHAPTER 3: YUKON

The Yukon Health Care Insurance Plan provides health care
coverage for other categories of individuals, as follows:
3.1 Eligibility
Returning Canadians — waiting period is applied
Eligibility requirements for insured health services are set
out in the Health Care Insurance Plan Act and Regulations, Permanent Residents — waiting period is applied
sections 2 and 4, and the Hospital Insurance Services Act and
Regulations, sections 2 and 4. There were no changes to the Minister’s Permit — waiting period is applied, if authorized
legislation in 2014–2015.
Foreign Workers — waiting period is applied, if holding
Subject to the provisions of these acts and regulations, every Employment Authorization
Yukon resident is eligible for and entitled to insured health
services on uniform terms and conditions. The term “resident” Clergy — waiting period is applied, if holding Employment
is defined using the wording of the Canada Health Act and Authorization
means a person lawfully entitled to be or to remain in Canada,
who makes his or her home and is ordinarily present in Yukon, Employment Authorizations must be in excess of 12 months.
but does not include a tourist, transient or visitor. Pursuant
to section 4(1) of the Yukon Health Care Insurance Plan
Regulations and the Yukon Hospital Insurance Services 4.0 PORTABILITY
Regulations, an insured person is eligible for and entitled to
insured services after midnight on the last day of the second
month following the month of arrival to the Territory. All 4.1 Minimum Waiting Period
persons returning to or establishing residency in Yukon are
required to complete this waiting period. The only exception Where applicable, the eligibility of all persons is administered
is for children adopted by insured persons, and for newborns. in accordance with the Interprovincial Agreement on Eligibility
and Portability. Under section 4(1) of both regulations, “an
The following persons are not eligible for coverage in Yukon: insured person is eligible for and entitled to insured services
after midnight on the last day of the second month following
■■ persons entitled to coverage from their home province the month of arrival to the Territory.” All persons entitled to
or territory (e.g., students and workers covered under coverage are required to complete the minimum waiting period
temporary absence provisions); with the exception of children adopted by insured persons
■■ visitors to Yukon; (see section 3.1), and newborns.
■■ refugee claimants;
■■ convention refugees; 4.2 Coverage During Temporary Absences
■■ inmates in federal penitentiaries; in Canada
■■ study permit holders, unless they are a child and they are The provisions relating to portability of health care insurance
listed as the dependent of a person who holds a one year during temporary absences outside Yukon, but within Canada,
work permit; and are defined in sections 5, 6, 7 and 10 of the Yukon Health Care
■■ employment authorizations of less than one year. Insurance Plan Regulations and sections 6, 7(1), 7(2) and 9 of
the Yukon Hospital Insurance Services Regulations.
The above persons may become eligible for coverage if they
meet one or more of the following conditions: The Regulations state that, “where an insured person is absent
from the Territory and intends to return, he/she is entitled
■■ establish residency in Yukon; to insured services during a period of 12 months continuous
■■ become a permanent resident; or absence.” Persons leaving Yukon for a period exceeding three
months are advised to contact Yukon Insured Health Services
■■ for inmates at the Whitehorse Correctional Centre, the day and complete a Temporary Absence form. Failure to do so may
following discharge or release if stationed in or a resident result in cancellation of coverage.
in Yukon.
Students attending educational institutions full-time outside
The number of registrants in the Yukon Health Care Insurance Yukon remain eligible for the duration of their academic studies.
Plan as of March 31, 2015 was 38,261. The Director, Insured Health and Hearing Services (the Director)
may approve other absences in excess of 12 consecutive months
upon receiving a written request from the insured person.

CHAPTER 3: YUKON
Requests for extensions must be renewed yearly and are subject to Persons leaving Yukon for a period exceeding three months
approval by the Director. are advised to contact Yukon Health Care Insurance Plan and
complete a Temporary Absence form. Failure to do so may
For temporary workers and missionaries, the Director may result in cancellation of the coverage.
approve absences in excess of 12 consecutive months upon
receiving a written request from the insured person. Requests The provisions for portability of health insurance during
for extensions must be renewed yearly and are subject to out-of-country absences for students, temporary workers
approval by the Director. and missionaries are the same as for absences within Canada
(see section 4.2 of this report).
The provisions regarding coverage during temporary absences
in Canada fully comply with the terms and conditions of Insured physician services provided to eligible Yukon residents
the Interprovincial Agreement on Eligibility and Portability temporarily outside the country are paid at rates equivalent
effective February 1, 2001. Definitions are consistent in to those paid had the service been provided in Yukon.
regulations, policies and procedures. Reimbursement is made to the insured person by the Yukon
Health Care Insurance Plan or directly to the provider of the
Yukon participates fully with the Interprovincial Medical insured service.
Reciprocal Billing Agreements and Hospital Reciprocal Billing
Agreements in place with all other provinces and territories Insured in-patient hospital services provided to eligible Yukon
with the exception of Quebec, which does not participate in residents outside Canada are paid at the rate established in
the medical reciprocal billing arrangement. Persons receiving the Standard Ward Rates Regulation for the Whitehorse
medical (physician) services in Quebec may be required to pay General Hospital.
directly and submit claims to the Yukon Health Care Insurance
Plan for reimbursement. Insured out-patient hospital services provided to eligible Yukon
residents outside Canada are paid at the rate established in the
The Hospital Reciprocal Billing Agreements provide for Charges for Out-Patient Procedures Regulation.
payment of insured in-patient and out-patient hospital services
to eligible residents receiving insured services outside Yukon,
but within Canada. 4.4 Prior Approval Requirement
The Medical Reciprocal Billing Agreements provide for There is no legislated requirement that eligible residents must
payment of insured physician services on behalf of eligible seek prior approval before seeking elective or emergency
residents receiving insured services outside Yukon, but within hospital or physician services outside Yukon or outside Canada.
Canada. Payment is made to the host province at the rates
established by that province.
Insured services provided to Yukon residents while temporarily

5.0 ACCESSIBILITY
absent from the territory are paid at the rates established by the
host province. 5.1 Access to Insured Health Services
There are no user fees or co-insurance charges under the Yukon
4.3 Coverage During Temporary Absences Health Care Insurance Plan or the Yukon Hospital Insurance
Outside Canada Services Plan. All services are provided on a uniform basis
and are not impeded by financial or other barriers. There is
The provisions that define portability of health care insurance no extra-billing in Yukon for any services covered by the Plan.
to insured persons during temporary absences outside Canada
are defined in sections 5, 6, 7, 9, 10 and 11 of the Yukon Health Access to hospital or physician services not available locally are
Care Insurance Plan Regulations and sections 6, 7(1), 7(2) provided through the Visiting Specialist Program, Telehealth
and 9 of the Yukon Hospital Insurance Services Regulations. Program or the Travel for Medical Treatment Program. These
programs ensure that there is minimal or no delay in receiving
Sections 5 and 6 currently state that, where an insured person medically necessary services.
is absent from Yukon and intends to return, he is entitled to
insured services during a period of 12 months continuous To improve access to insured health services, the number of
absence. Similarly to general temporary absences, regulatory visiting specialists continues to increase to better serve patients
work on coverage during temporary absences outside Canada in the territory.
is currently underway and will receive further public input prior
to enacting changes.

CHAPTER 3: YUKON
The Referred Care Clinic received additional funding to 5.3 Payments to Hospitals
increase operations to full time hours and increase mental
health nursing hours to full-time to enhance outreach services. The Government of Yukon funds the Yukon Hospital
Both of these initiatives will increase residents’ access to Corporation (Whitehorse General Hospital, Watson Lake
medical care and reduce the reliance and strain placed upon the Community Hospital, and Dawson City Community Hospital)
Emergency Department at the Whitehorse General Hospital. through global contribution agreements with the Department of
Health and Social Services. Global operations and maintenance
(O&M) and capital funding levels are negotiated and adjusted
5.2 Physician Compensation based on operational requirements and utilization projections
from prior years. In addition to the established O&M and
The Department of Health and Social Services seeks its capital funding set out in the agreement, provision is made
negotiating mandate from the Government of Yukon for the hospital to submit requests for additional funding
before entering into negotiations with the Yukon Medical assistance for implementing new or enhanced programs.
Association (YMA). The YMA and the government each
appoint members to the negotiating team. Meetings are The legislation governing payments made by the health care
held as required until an agreement has been reached. The plan to facilities that provide insured hospital services is the
YMA’s negotiating team then seeks approval of the tentative Hospital Insurance Services Plan Act and Regulations. The
agreement from the YMA membership. The Department legislation and regulations set out the legislative framework
seeks ratification of the agreement from the Government of for payment to hospitals for insured services provided by
Yukon. The final agreement is signed with the concurrence of that hospital to insured persons. No amendments were
both parties. The current Memorandum of Understanding will made to these sections of the legislation in 2014–2015.
expire on March 31, 2017.
The legislation governing payments to physicians and dentists

for insured services are the Health Care Insurance Plan Act and
the Health Care Insurance Plan Regulations. No amendments FEDERAL TRANSFERS
were made to these sections of the legislation in 2014–2015.
The Government of Yukon has acknowledged the federal
The fee-for-service system is used to reimburse the majority contributions provided through the Canada Health Transfer
of physicians providing insured services to residents. Other (CHT) in its 2014–2015 annual Main Estimates and
systems of reimbursement include contract payments and Public Accounts publications, which are available publicly.
sessional payments for services in Whitehorse as well as rural Section 3(1) (d) and (e) of the Health Care Insurance Plan Act
communities in the territory. and section 3 of the Hospital Insurance Services Act acknowledge
the contribution of the Government of Canada.

CHAPTER 3: YUKON
REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

Public Facilities1 2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
2. Number (#). 2 15 15 15 15 14
3. Payments for insured health services ($). 3 51,734,000 57,655,576 58,943,422 70,087,418 72,452,732



2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
6. Total number of claims, in-patient (#). 1,047 996 1,173 1,197 1,205
7. Total payments, in-patient ($). 4 16,583,657 13,507,016 15,890,700 16,562,129 16,703,371

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.
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).

CHAPTER 3: YUKON

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
14. Number of participating physicians (#). 69 74 70 71 70

methods ($). 21,549,640 22,387,839 22,690,228 24,409,655 26,949,206

physicians paid through fee-for-service ($).5 17,701,880 18,373,627 18,660,715 18,817,879 20,295,869

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 3,185,612 3,219,166 3,563,528 3,503,179 3,718,480

21. Number of services (#). not available not available not available not available not available
22. Total payments ($). not available not available not available not available not available

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
23. Number of participating dentists (#). 6 2 3 3 2 2
24. Number of services provided (#). 6 4 14 26 6 6
25. Total payments ($). 4,631 13,913 21,845 3,827 8,117
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.
6. Includes direct billings for insured surgical-dental services received outside the territory.

NORTHWEST TERRITORIES

The Department of Health and Social Services (DHSS) works
with the eight Health and Social Services Authorities (HSSAs) 1.1 Health Care Insurance Plan and
to administer, manage, and deliver insured services in the
Northwest Territories (NWT). Public Authority
During the 2014–2015 fiscal year DHSS carried out the The Northwest Territories Health Care Plan consists of the
following legislative activities related to health care services: Medical Care Plan and the Hospital Insurance Plan. The public
authority responsible for the administration of the Medical
■■ An Act to Amend the Hospital Insurance and Health and Care Plan is the Director of Medical Insurance, appointed
Social Services Administration Act was introduced. The Bill by the Minister of Health and Social Services (the Minister),
will allow for the establishment of a territorial health and under the Medical Care Act. The Minister establishes Health
social services authority to replace a number of Boards of and Social Service Authorities’ Boards of Management as
Management. The Bill will also require the Minister of per section 10 of the Hospital Insurance and Health and Social
Health and Social Services to develop a territorial plan Services Administration Act (HIHSSA) to, among other things,
for health and social services. Together these changes are administer the Hospital Insurance Plan.
intended to improve system integration and to increase
system accountability.
■■ A new Health and Social Services Professions Act was
passed. This Act allows for the regulation of several There are eight Health and Social Service Authorities
health and social services professions under one legislative (HSSAs): Tlicho Community Services Agency (TCSA),
model. This will allow DHSS to modernize the existing Stanton Territorial Health Authority, Yellowknife HSSA,
out-dated professional legislation in a more efficient and Sahtu HSSA, Beaufort-Delta HSSA, DehCho HSSA,
consistent manner. Fort Smith HSSA and Hay River HSSA. They report to
■■ Work on drafting a new Mental Health Act continued, with the Minister and the Department of Health and Social
the intent to modernize the legislation. The Act governs Services (DHSS), and plan, manage, deliver and evaluate
the treatment of persons with mental disorders, including a wide spectrum of health and social services at both the
provisions for involuntary psychiatric assessment, admission community and facility level throughout the NWT. Boards
to a hospital and consent to psychiatric treatment. of Management for each region manage, control and operate
health and social services facilities within the government’s
Additional information on DHSS legislative initiatives is existing resources, policies and directives; and are accountable
available in the Health and Social Services Annual Report, to the Minister.
2014–2015.
The Minister appoints the Director of Medical Insurance who
is responsible for administering the Medical Care Act and its
regulations. The Director prepares an annual report for the
Minister on the operation of the Medical Care Plan. This
report can be found within the DHSS Annual Report.

CHAPTER 3: NORTHWEST TERRITORIES
Boards of Management are established by the Minister ■■ radiology and rehab therapy (physio, audio, occupational
to administer the Hospital Insurance Plan. The Minister and speech);
appoints a chairperson and members to the Board of ■■ psychiatric and psychological services within an approved
Management for each HSSA in the NWT. The chairperson’s program; and
term is indefinite and members serve for three years. The
exception to this is the TCSA where the Tlicho community ■■ detoxification at approved centers.
governments are responsible for appointing one member to the
Insured out-patient hospital services include:
Board. The Minister Responsible for Aboriginal Affairs and
Intergovernmental Relations (DAAIR) appoints a chairperson ■■ laboratory tests;
after consulting with the board members. Members serve for a
maximum of four years and the chairperson’s term is fixed by ■■ diagnostic imaging (including interpretations when needed);
the Minister of DAAIR. The Minister may appoint a Public ■■ physiotherapy, speech and language pathology therapy and
Administrator to assume the role of a board of management occupational therapy;
in certain circumstances if the Minister feels it is necessary
■■ minor medical and surgical procedures and related supplies;
to do so.
and
The Director of Medical Insurance and the Boards of Man ■■ psychiatric and psychological services under an approved
agement are responsible to the Minister, as per section 8(1)(b) hospital program.
of the Canada Health Act.
The Minister may change, add or remove insured hospital
services, and determine whether public consultation will occur.
As outlined in the Government of the NWT Medical Travel
As part of the Government of the Northwest Territories annual Policy, travel assistance is provided to residents who require
audit, the Office of the Auditor General of Canada audits medically necessary insured services that are not available in
payments under the Hospital Insurance Plan and the Medical their home community or elsewhere in the NWT. This ensures
Care Plan. that residents of the NWT have reasonable access to insured
hospital and physician services.
2.0 COMPREHENSIVENESS 2.2 Insured Physician Services

2.1 Insured Hospital Services The NWT Medical Care Act and the NWT Medical Care
Regulations provide for insured physician services. Services
Insured hospital services in the Northwest Territories (NWT) provided in approved facilities by physicians, nurses, nurse
are provided under the Hospital Insurance and Health and Social practitioners and midwives are considered insured services
Services Administration Act. under the health care plan. These professionals are required
by legislation to be licensed to practice in the NWT under
During the reporting period, insured hospital services were the Medical Profession Act (physicians), Nursing Profession Act
provided to in-patients and out-patients by 27 health facilities (nurses and nurse practitioners) and the Midwifery Profession Act
throughout the NWT. Consistent with Section 9 of the Canada (registered midwives).
Health Act, the NWT offers a comprehensive range of services
to its residents. For the period 2014–2015, there were 331 licensed physicians
(resident, locum and visiting) operating in the NWT.
Insured in-patient hospital services include:
Physicians may opt out and collect fees other than under the
■■ meals and accommodation at the ward level; Medical Care Plan by providing written notice to the Director
■■ required nursing services; of Medical Insurance. There were no opted-out physicians in
the NWT during the reporting period.
■■ laboratory, diagnostic and imaging services (along with
necessary interpretations); The Medical Care Plan insures all medically necessary physician
■■ drugs, biologicals and other preparations administered services such as:
in the hospital; ■■ diagnosis and treatment of illness and injury;
■■ surgical supplies and use of operating room;
■■ surgery, including anaesthetic services;
■■ case room and anaesthesiology services;
■■ obstetrical care, including prenatal and postnatal care; and
■■ eye examinations, treatment and operations provided by
an ophthalmologist.

The Director of Medical Insurance is responsible for recom- compensation acts. These policies are available on their website
mending an insured services tariff for services payable by at www.wscc.nt.ca.
the NWT Medical Care Plan for the Minister’s approval.
The Minister ultimately determines if services will be added, The process used to make changes to the list of uninsured
altered or removed from the tariff by: hospital, physician and surgical-dental services is described
in sections 2.1 and 2.2.
■■ establishing a medical care plan that provides insured services
to insured persons by medical practitioners that will qualify
and enable the NWT to receive transfer payments from the 3.0 UNIVERSALITY
Government of Canada under the Canada Health Act; and
■■ approving the fees and charges itemized in the tariff that
may be paid in respect to insured services rendered by 3.1 Eligibility
medical practitioners in the NWT and the conditions
The Medical Care Act and the Hospital Insurance and Health and
under which fees and charges are payable.
Social Services Administration Act (HIHSSA) define eligibility
for the NWT Health Care Plan. The NWT uses guidelines
that are consistent with the legislation and Interprovincial
2.3 Insured Surgical-Dental Services Agreement on Eligibility and Portability to determine
Licensed oral surgeons may submit claims for insured surgical- eligibility in order to fulfill obligations of section 10 in
dental work in the NWT. The Province of Alberta’s Schedule the Canada Health Act.
of Oral and Maxillofacial Surgery Benefits is used as a guide.
Individuals ineligible for NWT health care coverage are
members of the Canadian Forces, federal inmates and new
residents who have not completed the minimum waiting
2.4 Uninsured Hospital, Physician and period. For persons moving back to Canada, eligibility is
Surgical-Dental Services restored when permanent residency is established.
Not all services provided by hospitals, medical practitioners In order to register for the NWT Health Care Plan, residents
and dentists are covered under the Health Care Plan. Some fill out an application form and provide applicable supporting
uninsured services include: documentation (e.g., visa, immigration papers, and proof of
residency). Residents may register prior to the date they become
■■ in-vitro fertilization; eligible. Registration is directly linked to eligibility for coverage
■■ third party examinations; and claims are only paid if the client has registered.
■■ dental services that are not surgical in nature; As of March 31, 2015, there were 43,436 individuals registered
■■ group immunizations; with the NWT Health Care Plan.
■■ medical-legal services;
■■ advice or prescriptions done over the phone; 3.2 Other Categories of Individuals
■■ services rendered to the physician’s family;
Holders of employment visas, student visas and, in some
■■ dressings, bandages, drugs and other consumables cases, visitor visas are covered if they meet the provisions
used at the medical practitioner’s office; of the Eligibility and Portability Agreement and guidelines
■■ plaster; and for health care plan coverage.
■■ services carried out by people who usually are not
medical practitioners such as osteopaths, naturopaths
and chiropractors. Physiotherapy, psychiatry and
4.0 PORTABILITY
psychological therapies are not covered if delivered
in a non-approved location.
For NWT residents to receive items and/or services that
Waiting periods for persons moving to the NWT are
are generally considered uninsured under the health care
consistent with the Interprovincial Agreement on Eligibility
plan, prior approval is required. A Medical Advisor makes
and Portability. The waiting period ends the first day of the
recommendations to the Director of Medical Insurance
third month of residency for those moving permanently to
regarding the appropriateness of the request.
the NWT, or the first day of the thirteenth month for those
The Workers’ Safety and Compensation Committee has whose work term was for one year and has been extended.
several policies that are applied when interpreting workers’ Confirmation of extension may be required.

4.2 Coverage During Temporary Absences 5.0 ACCESSIBILITY

in Canada
Section 4(2) of the Medical Care Act provides NWT residents 5.1 Access to Insured Health Services
with access to insured health coverage while temporarily out of
the NWT but still in Canada, consistent with section 11(1) (b)(i) The Government of the NWT Medical Travel Policy provides
of the Canada Health Act. The Department of Health and Social NWT residents with assistance to access medically necessary
Services (DHSS) adheres to the Interprovincial Agreement on insured services not available in their home community
Eligibility and Portability as described in the NWT Health or in the NWT, consistent with section 12(1)(a) of the
Care Plan Registration Manual. Canada Health Act.
Once an individual has filled out the Temporary Absence form At the end of 2014–2015, the partnership with Dalhousie
and it is approved by DHSS, NWT residents are covered for up University providing psychiatric service delivery through
to one year of temporary absence for work, travel or holidays. telepsychiatry came to an end. During 2014–2015, Dalhousie
Full-time students attending post-secondary school are covered psychiatrists were on-site in the NWT for approximately
as well. The full cost of insured services is paid for all services 19 weeks and also provided services via telepsychiatry for
received in other Canadian jurisdictions. an additional 14 weeks. The program provided all aspects of
psychiatric care, including travel clinics, consultations, and
When a valid NWT health care card is produced, most doctor emergency assessments.
visits and hospital services are billed directly to the Department.
During the reporting period, 23 million dollars were paid out Diagnostic Imaging/Picture Archiving Communication
for hospital in-patient and out-patient services in other provinces System (DI/PACS) is available everywhere that digital imaging
and territories. Reimbursement guidelines exist for patients services are offered. DI/PACS has moved x-rays from film to
having to pay up front for medically required services. digital format. Radiologists in Yellowknife and the south can
review results in as fast as 35 minutes. This ultimately provides
The NWT participates in both the Hospital Reciprocal Billing NWT residents with access to specialists in southern Canada
Agreement and the Medical Reciprocal Billing Agreement without having to spend extended periods of time away from
with other jurisdictions (except Quebec). home and family.
Extra-billing is not permitted in the NWT, in adherence to

4.3 Coverage During Temporary Absences section 18 of the Canada Health Act. The only exception is if
a medical practitioner opts out of the Medical Care Plan and
Outside Canada collects his or her own fees. This did not occur during the
As per section 4(3) of the Medical Care Act and section 11(1)(b) (ii) reporting period.
of the Canada Health Act, the NWT provides reimbursement
for NWT residents who require medically necessary services
while temporarily outside Canada. Individuals are required 5.2 Physician Compensation
to pay up front and seek reimbursement upon their return to
The Department, in close consultation with the NWT Medical
the NWT. Costs for eligible services rendered outside Canada
Association, sets physician compensation. Generally, family and
will be reimbursed up to the amounts payable in the NWT.
specialist practitioners are compensated through contractual
Residents temporarily out of Canada may receive coverage
agreements with the Government of NWT, while the remainder
for up to one year; however, prior approval is required as well
are compensated on a fee-for-service basis. Fee-for-service rates
as documentation proving the NWT will be the individual’s
in the NWT are itemized in the Insured Services Tariff approved
permanent residence upon return.
by the Minister in accordance with the NWT Medical Care Act.
4.4 Prior Approval Requirement

Prior approval is required for elective services rendered in
other provinces and outside Canada. All services from private
facilities require prior approval as well.

5.3 Payments to Hospitals 6.0 RECOGNITION GIVEN TO

Contribution agreements between the Department of Health FEDERAL TRANSFERS
and Social Services and the Boards of Management for each
Health and Social Service Authority (HSSA) dictate payments Federal funding from the Canada Health Transfer has been
made to hospitals. Government budgets, resources and levels recognized and reported by the Government of NWT through
of services offered determine the allocated amounts. the 2014–2015 Main Estimates.
Payments to HSSAs providing insured hospital services are The Main Estimates report (noted above) is presented annually
governed under the Hospital Insurance and Health and Social to the Legislative Assembly and represents the government’s
Services Administration Act and the Financial Administration Act. financial plan.
A comprehensive budget is used to fund hospitals in the NWT.

REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

2. Number (#). 27 27 27 27 27
3. Payments for insured health services ($). 54,728,540 1

57,225,434 1
62,112,381 1
62,499,951 1
69,659,642 1


for insured health services ($). not applicable not applicable not applicable not applicable not applicable

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

All data are subject to future revisions. Payment information for #3 and # 17 have been restated for all years to better reflect the actual expenditures on hospital and
physician services.
1. Payments for insured health services are estimated and include only those health services occurring within acute care facilities (e.g., hospitals that offer both
in‑patient and outpatient services).


2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
14. Number of participating physicians (#). 292 2

284 2
297 2
297 2
331 2

methods ($). 45,853,657 3
45,872,806 3
48,171,561 3
50,711,751 3
53,456,730 3


2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 4,944,840 4,591,143 5,336,700 5,184,693 5,578,109

21. Number of services (#). 117 102 115 111 66
22. Total payments ($). 14,825 9,841 18,672 11,348 4,820

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
23. Number of participating dentists (#). not available not available not available not available not available
24. Number of services provided (#). not available not available not available not available not available
2. Estimate based on total active physicians for each fiscal year.

3. Payments are based on an estimate of expenditures for physician services on NWT residents (including physician remuneration and clinic costs).

NUNAVUT

The Department of Health faces many unique challenges when
providing for the health and well-being of Nunavummiut. 1.1 Health Care Insurance Plan and
The population of 36,5851 is approximately 81 percent Inuit,
and 49 percent of the population is under the age of 25 years Public Authority
(17, 943 people).2 The territory is made up of 25 communities The health care insurance plans of Nunavut, including physician
located across three time zones and divided into three regions: and hospital services, are administered by the Department of
the Qikiqtaaluk (or Baffin), the Kivalliq and the Kitikmeot. Health on a non-profit basis.
The Government of Nunavut, where possible, incorporates The Medical Care Act (NWT, 1988 and as duplicated for
Inuit societal values into program and policy development, as Nunavut by section 29 of the Nunavut Act, 1999) governs the
well as into service design and delivery. The delivery of health entitlement to and payment of benefits for insured medical
services in Nunavut is based on a primary health care model. services. The Hospital Insurance and Health and Social Services
Nunavut’s primary health care providers are family physicians, Administration Act (NWT, 1988 and as duplicated for Nunavut
nurse practitioners, midwives, community health nurses, and by section 29 of the Nunavut Act, 1999) enables the establish-
other allied health professionals. ment of hospital and other health services.
In 2014–2015, the territorial operations and maintenance The Department is responsible for delivering health care services
budget for the Department of Health was $322,000,000, to Nunavummiut, including the operation of community health
including supplementary appropriations. 3 One third of the centres, regional health centres, and a hospital. There are three
Department’s total operational budget was spent on costs regional offices that manage the delivery of health services at
associated with medical travel and treatment provided in a regional level. Iqaluit operations are administered separately.
out-of-territory facilities. Nunavut is a vast territory with The Government of Nunavut opted for decentralization to
a low population density and limited health infrastructure, regional offices to support front-line workers and community
for example, diagnostic services; therefore, access to a range based delivery of a wide range of health programs and services.
of hospital and specialist services often requires that residents
be sent out of the territory for care.
In 2014–2015 an additional $12,423,000 was allocated to

the Department for capital projects.4 The Department of Legislation governing the administration of health services
Health 2014–2015 capital projects included: the replacement in Nunavut was carried over from the Northwest Territories
of the Taloyoak Health Centre and preliminary work on the (as Nunavut statutes) pursuant to the Nunavut Act. The Medical
replacement of the Arctic Bay Health Centre.5 Care Act governs who is covered by the Nunavut Health
Care Plan and the payment of benefits for insured medical
services. Section 23(1) of the Medical Care Act requires the
Minister responsible for the Act to appoint a Director of
Medical Insurance.
1. Nunavut Bureau of Statistics July 1, 2015 http://www.stats.gov.nu.ca/en/Population%20estimate.aspx

2. Nunavut Bureau of Statistics July 1, 2015 http://www.stats.gov.nu.ca/en/Population%20estimate.aspx
3. Department of Health, Division of Finance Freebalance Report
4. 2014/2015 Capital Estimates, Government of Nunavut
5. 2014/2015 Capital Estimates, Government of Nunavut

CHAPTER 3: NUNAVUT
The Director is responsible for the administration of the Act Public health services are provided at public health clinics
and regulations. Section 24 requires the Director to submit an located in Rankin Inlet and Iqaluit. Public health programing
annual report on the operation of the Nunavut Health Care is provided in the remaining communities through the local
Plan to the Minister for tabling in the Legislative Assembly. On health centre. The Department also operates a Family Practice
November 5, 2014 the Director of Medical Insurance Annual Clinic, led by Nurse Practitioners, in Iqaluit.
Report 2013–2014 was tabled in the Legislative Assembly.
The Familiy Practice Clinic has the ability to consult physicians
and specialists as needed. It was established in 2006 with
1.3 Audit of Accounts funding from the Primary Health Care Transition Fund,
and has been successful in helping to reduce pressure on the
The Auditor General of Canada is the auditor of the emergency and out-patient departments of the QGH during
Government of Nunavut in accordance with section 30.1 working hours. The clinic provides a steady source of primary
of the Financial Administration Act (Nunavut, 1999). The care appointments and initiatives, such as a Diabetes Clinic and
Auditor General is required to conduct an annual audit of a Sexual Health Program.
the transactions and consolidated financial statements of the
Government of Nunavut. The most recent audited report The Department is responsible for authorizing, licensing,
was issued October 30, 2014. inspecting and supervising all health facilities in the territory.
Insured in-patient hospital services include: accommodation

2.0 COMPREHENSIVENESS and meals at the standard ward level; necessary nursing
services; laboratory, radiological and other diagnostic
procedures, together with the necessary interpretations; drugs,
biological and related preparations prescribed by a physician
2.1 Insured Hospital Services and administered in hospital; routine surgical supplies; use
Insured hospital services are provided in Nunavut under the of operating room, case-room and anaesthetic facilities; use
authority of the Hospital Insurance and Health and Social Services of radiotherapy and physiotherapy services where available;
Administration Act and regulations, sections 2 to 4. No amend- psychiatric services provided under an approved program;
ments were made to the Act or regulations in 2014–2015. services rendered by persons who are paid by the hospital.
In 2014–2015 insured hospital services were delivered in Out-patient services include: laboratory tests and x-rays,
28 facilities across Nunavut including: one general hospital including interpretations, when requested by a physician and
(Iqaluit); two regional health facilities (Rankin Inlet and performed in an out-patient facility or in an approved hospital;
Cambridge Bay); 22 community health centres; one public hospital services in connection with most minor medical and
health facility (Iqaluit); and one family practice clinic (Iqaluit). surgical procedures; physiotherapy, occupational therapy,
Rehabilitative treatment is available through the Timimut limited audiology and speech therapy services in an out-patient
Ikajuksivik Centre located in Iqaluit or via contracted services facility or in an approved hospital; and psychiatric services
in other regions. provided under an approved hospital program.
The Qikiqtani General Hospital (QGH) is currently the only The Department makes the determination to add insured
acute care facility in Nunavut providing a range of in-and out- hospital services based on the availability of appropriate
patient hospital services as defined by the Canada Health Act. resources, equipment and overall feasibility in accordance
QGH offers 24-hour emergency services, in-patient care with financial guidelines set by the Department and with the
(including obstetrics, pediatrics and palliative care), surgical approval of the Financial Management Board. No new services
services, laboratory services, diagnostic imaging, respiratory were added in 2014–2015 to the list of insured hospital services.
therapy, and health records and information.
Currently Rankin Inlet is providing 24-hour care for in-patients; 2.2 Insured Physician Services
out-patients receive care by on-call staff. Cambridge Bay is
providing daily clinic hours, and emergency care is available, The Medical Care Act, section 3(1), and Medical Care Regulations,
on-call, 24-hours a day. There are also a limited number of section 3, provide for insured physician services in Nunavut. No
birthing beds at both facilities. Other community health centres amendments were made to the Act or regulations in 2014–2015.
provide public health services, out-patient services and urgent The Nursing Act allows for licensure of nurse practitioners
treatment services. in Nunavut; this permits nurses to deliver insured services
in Nunavut.

CHAPTER 3: NUNAVUT
Physicians must be in good standing with a College of Physicians 2.3 Insured Surgical-Dental Services
and Surgeons from a Canadian jurisdiction, and be licensed to
practice in Nunavut. The Government of Nunavut’s Medical Dentists providing insured surgical-dental services under
Registration Committee currently manages this process for the Nunavut Health Care Plan must be licensed pursuant
Nunavut physicians. Nunavut recruits and hires its own family to the Dental Professions Act (NWT, 1988 and as duplicated
physicians, and accesses specialist services primarily from its for Nunavut by section 29 of the Nunavut Act, 1999). Billing
main referral centres in Ottawa, Winnipeg, and Yellowknife. numbers are provided for billing the Plan regarding the
Recruitment of full-time family physicians has improved provision of insured dental services.
significantly and there are 26 family physician positions, covered
by a combination of locums and full-time physicians, funded Insured dental services are limited to those dental-surgical
through the Department, providing over 7,400 days of service procedures scheduled in the regulations, requiring the unique
annually across the territory. capabilities of a hospital for their performance; for example,
orthognathic surgery. Oral surgeons are brought to Nunavut on
Of the 26 full-time family physician positions in Nunavut, a regular basis, but on rare occasions, for medically complicated
16 are in the Qikiqtaaluk region; 7.5 in the Kivalliq region; situations, patients are flown out of the territory.
and 2.5 in the Kitikmeot region. There are also 1.5 general
surgeons, 1 anaesthetist, and 1 pediatrician at the QGH. The addition of new surgical-dental services to the list of
Visiting specialists, general practitioners and locums also insured services requires government approval. No new services
provide insured physician services; these arrangements are were added to the list in 2014–2015.
made by each of the Department’s three regions.
Physicians can elect to collect fees other than those under the 2.4 Uninsured Hospital, Physician and
Medical Care Plan in accordance with section 12(2)(a) or (b)
of the Medical Care Act by notifying the Director in writing.
An election can be revoked the first day of the following Services provided under the Workers’ Compensation Act
month after a letter to that effect is delivered to the Director. (NWT, 1988 and as duplicated for Nunavut by section 29
In 2014–2015, no physicians provided written notice of of the Nunavut Act, 1999) or other Acts of Canada, except
this election. the Canada Health Act, are excluded.
All physicians practicing in Nunavut are under contract with Services provided by physicians that are not insured include:
the Department. In 2014–2015, 289 physicians provided yearly physicals; cosmetic surgery; services that are considered
service in Nunavut. experimental; prescription drugs; physical examinations done at
the request of a third party; optometric services; dental services
Insured physician services refer to all services rendered by med-
other than specific procedures related to jaw injury or disease;
ical practitioners that are medically required. Where insured
the services of chiropractors, naturopaths, podiatrists, osteo-
services are unavailable in some places in Nunavut, the patient
paths and acupuncture treatments; and physiotherapy, speech
is referred to another jurisdiction to obtain the insured service.
therapy and psychology services received in a facility that is not
Nunavut has health service agreements with medical and treat-
an insured out-patient facility (hospital).
ment centres in Ottawa, Winnipeg, Churchill, Yellowknife
and Edmonton. These are the out-of-territory sites to which Services not covered in a hospital include: hospital charges
Nunavut mainly refers its patients to access medical services above the standard ward rate for private or semi-private
not available within the territory. accommodation; services that are not medically required, such
as cosmetic surgery; services that are considered experimental;
The addition or deletion of insured physician services requires
ambulance charges (except inter-hospital transfers); dental
government approval. For this, the Director of Medical
services, other than specific procedures related to jaw injury
Insurance would become involved in negotiations with a
or disease; and alcohol and drug rehabilitation, without
collective group of physicians to discuss the service. Then
prior approval.
the decision of the group would be presented to Cabinet for
approval. No insured physician services were added or deleted In 2014–2015 the Qikiqtani General Hospital charged a
in 2014–2015. $2,322 per diem rate for services provided for non-Canadian
resident stays. The inpatient rate charged in Rankin Inlet and
Cambridge Bay was $1,304.

CHAPTER 3: NUNAVUT
When residents are sent out of the territory for services, the Members of the Canadian Armed Forces and inmates of a
Department relies on the policies and procedures guiding that federal penitentiary are not eligible for registration. These
particular jurisdiction when they provide services to Nunavut groups are granted first-day coverage under the Nunavut
residents that could result in additional costs, only to the extent Health Care Plan upon discharge.
that these costs are covered by Nunavut’s Medical Insurance
Plan (see section 4.2 below). Any query or complaint is handled Pursuant to section 7 of the Interprovincial Agreement on
on an individual basis with the jurisdiction involved. Eligibility and Portability, individuals in Nunavut who are
temporarily absent from their home province or territory and
The Department also administers the Non-Insured Health who are not establishing residency in Nunavut remain covered
Benefits (NIHB) Program, on behalf of Health Canada, for by their home provincial or territorial health insurance plans
Inuit and First Nations residents in Nunavut. NIHB covers a for up to one year.
co-payment for medical travel, accommodations and meals at
boarding homes (in Ottawa, Winnipeg, Churchill, Edmonton, On March 31, 2015, 36,667 individuals were registered with
Yellowknife and Iqaluit), prescription drugs, dental treatment, the Nunavut Health Care Plan, up by 1350 from the previous
vision care, medical supplies and prostheses, and a number of year. There are no formal provisions for Nunavut residents to
other incidental services. opt out of the Nunavut Health Care Plan.

Non-Canadian holders of employment visas of less than
12 months, foreign students with visas of less than 12 months,
3.1 Eligibility transient workers, and individuals holding a Minister’s Permit
Eligibility for the Nunavut Health Care Plan is briefly defined (with the possible exception of those holding a temporary
under sections 3(1), (2), and (3) of the Medical Care Act. The resident permit who may be reviewed on a case by case basis)
Department also adheres to the Interprovincial Agreement are not eligible for coverage. When unique circumstances occur,
on Eligibility and Portability, as well as internal guidelines. assessments are done on an individual basis. This is consistent
No amendments were made to the Act or regulations with section 15 of the Northwest Territories’ Guidelines for
in 2014–2015. Health Care Plan Registration, which was adopted by Nunavut
in 1999.
Subject to these provisions, every Nunavut resident is eligible
for and entitled to insured health services on uniform terms
and conditions. A resident means a person lawfully entitled to 4.0 PORTABILITY
be in or to remain in Canada, who makes his or her home and
is ordinarily present in Nunavut, but does not include a tourist,
transient or visitor to Nunavut. Eligible residents receive a 4.1 Minimum Waiting Period
health card with a unique health care number.
Consistent with section 3 of the Interprovincial Agreement on
Registration requirements include a completed application form Eligibility and Portability, the waiting period before coverage
and supporting documentation. A health care card is issued to begins for individuals moving within Canada is three months,
each resident. To streamline document processing, a staggered or the first day of the third month following the establishment
renewal process is used. No premiums exist. Coverage under of residency in a new province or territory, or the first day of
the Nunavut Medical Insurance Plan is linked to verification of the third month when an individual, who has been temporarily
registration, although every effort is made to ensure registration absent from his or her home province, decides to take up per-
occurs when a coverage issue arises for an eligible resident. For manent residency in Nunavut.
non-residents, a valid health care card from their home province
or territory is required.
Coverage generally begins the first day of the third month after
arrival in Nunavut, but first-day coverage is provided under
in Canada
a number of circumstances, for example, newborns whose The Medical Care Act, section 4(2), prescribes the benefits
mothers or fathers are eligible for coverage. Permanent resi- payable where insured medical services are provided outside
dents (landed immigrants), returning Canadians, repatriated Nunavut, but within Canada. The Hospital Insurance and
Canadians, returning permanent residents, and non-Canadians Health and Social Services Administration Act, sections 5(d) and
who have been issued an employment visa for a period of 28(1)(j)(o), provide the authority for the Minister to enter into
12 months or more, are also granted first-day coverage. agreements with other jurisdictions to provide health services
to Nunavut residents, and the terms and conditions of payment.

CHAPTER 3: NUNAVUT
No legislative or regulatory changes were made in 2014–2015 4.4 Prior Approval Requirement
with respect to coverage outside Nunavut.
Prior approval is required for elective services provided in pri-
Students studying outside Nunavut must notify the vate facilities in Canada or in any facility outside the country.
Department and provide proof of enrollment to ensure
continuing coverage. Requests for extensions must be
renewed yearly and are subject to approval by the Director.
Temporary absences for work, vacation or other reasons for
5.0 ACCESSIBILITY
up to one year are approved by the Director upon receipt of
a written request from the insured person. The Director may
approve absences in excess of 12 continuous months upon
5.1 Access to Insured Health Services
receiving a written request from the insured individual. The Medical Care Act, section 14, prohibits extra-billing by
physicians unless the medical practitioner has made an election
The provisions regarding coverage during temporary absences
that is still in effect. Access to insured services is provided on
in Canada fully comply with the terms and conditions of the
uniform terms and conditions. To break down the barrier posed
Interprovincial Agreement on Eligibility and Portability.
by distance and cost of travel, the Government of Nunavut
Nunavut participates in physician and hospital reciprocal
provides medical travel assistance. Interpretation services in
billing. As well, special bilateral agreements are in place with
Inuktut are also provided to patients in any health care setting.
Ontario, Manitoba, Alberta, and the Northwest Territories.
The Hospital Reciprocal Billing Agreements provide payment The Qikiqtani General Hospital (QGH) in Iqaluit is currently
of in- and out-patient hospital services to eligible Nunavut the only acute care hospital facility in Nunavut. The hospital
residents receiving insured services outside the territory. has a total of 35 beds available for acute, rehabilitative,
High-cost procedure rates, newborn rates, and out-patient palliative and chronic care services and currently 20 general
rates are based on those established by the Interprovincial purpose beds are in use due to capacity and need. There are
Health Insurance Agreements Coordinating Committee. also four birthing rooms and six day surgery beds. The facility
The Physician Reciprocal Billing Agreements provide payment provides in-patient, out-patient and 24-hour emergency
of insured physician services on behalf of eligible Nunavut services. On-site physicians provide emergency services on
residents receiving insured services outside the territory. rotation. Medical services provided include: an ambulatory
Payment is made to the host province at the rates established care/out-patient clinic, limited intensive care services, and
by that province. general medical, maternity and palliative care. Surgical services
provided include ophthalmology, urology, orthopaedics,
gynaecology, paediatrics, general surgery, emergency trauma,
4.3 Coverage During Temporary Absences otolaryngology and dental surgery under general anesthesia
Outside Canada and conscious sedation. Patients requiring specialized surgeries
are sent to other jurisdictions. Diagnostic services include:
The Medical Care Act, section 4(3), prescribes the benefits radiology, laboratory, electrocardiogram and CT scans.
payable where insured medical services are provided outside
Canada. The Hospital Insurance and Health and Social Services Outside of Iqaluit, out-patient and 24-hour emergency nursing
Administration Act, section 28(1)(j)(o), provides the authority services are provided by local health centres in Nunavut’s
for the Minister to set the terms and conditions of payment 24 other communities.
for services provided to Nunavut residents outside Canada.
Individuals are granted coverage for up to one year if they are Nunavut has two Continuing Care Centres located in Igloolik
temporarily out of the country for any reason, although they and Gjoa Haven. These facilities provide full time nursing and
must give prior notice in writing. For services provided to personal care to adults. Each facility has 10 beds.
residents who have been referred out of the country for highly Nunavut has agreements in place with a number of out-of-
specialized procedures unavailable in Nunavut and Canada, territory regional health authorities and specific facilities to
Nunavut will pay the full cost. For non-referred or emergency provide medical specialists and other visiting health practitioner
services, the payment for hospital services is $2,322 per day services. The following specialist services were provided in
and for out-patient care it is $288 per day. Nunavut during 2014–2015 under the visiting specialists
Insured physician services provided to eligible residents program: ophthalmology, orthopaedics, internal medicine,
temporarily outside the country are paid at rates equivalent otolaryngology, neurology, rheumatology, dermatology,
to those paid had that service been provided in the territory. paediatrics, obstetrics/gynecology, urology, respirology,
Reimbursement is made to the insured individual or directly cardiology, physiotherapy, occupational therapy, psychiatry,
to the provider of the insured service. oral surgery, and allergist. Visiting specialist clinics are held
depending on demand and availability of specialists.

CHAPTER 3: NUNAVUT
Nunavut’s Telehealth network, linking all 25 communities, 5.3 Payments to Hospitals

allows for the delivery of a broad range of services over
distances including specialist consultation services such as Funding for the Qikiqtani General Hospital, regional health
dermatology, psychiatry and internal medicine; rehabilitation facilities and community health centres is provided through the
services; regularly scheduled counseling sessions; family Government of Nunavut’s budget process.
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. FEDERAL TRANSFERS
For services and equipment unavailable in Nunavut, patients are Nunavummiut are aware of ongoing federal contributions
referred to other jurisdictions. through press releases and media coverage. The Government of
Nunavut has also recognized the federal contribution provided
through the Canada Health Transfer in various published
5.2 Physician Compensation documents. For fiscal year 2014–2015, they included:
All full-time physicians in Nunavut work under contract with ■■ 2014–2015 Budget Address; and
the Department. The terms of the contracts are set by the ■■ 2015–2018 Government of Nunavut Business Plan.
Department. Visiting consultants are paid a daily contract
rate for their professional services. Rates vary based on
services rendered.

CHAPTER 3: NUNAVUT
REGISTERED PERSONS
2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
1. Number as of March 31st (#).1 35,515 35,893 35,041 35,897 36,667

2. Number (#). 28 28 28 28 28



2010–2011 2011–2012 2012–2013 2013–2014 2014–2015

11. Total payments, in-patient ($). 0 0 4,410 20,574 0
13. Total payments, out-patient ($). 0 0 0 20,041 25,388
1. The difference in the number of registered Nunavut residents and those covered under the Nunavut Health Care Plan is due to delays in the reconciliation of data
on residents who have left the territory.

CHAPTER 3: NUNAVUT

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
14. Number of participating physicians (#). 225 375 409 349 289

methods ($). 3 not available not available not available not available not available

physicians paid through fee-for-service ($).2,3 312,786 334,539 403,418 348,473 54,501

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
20. Total payments ($). 4 5,901,962 6,393,341 6,341,047 6,855,743 7,607,809

21. Number of services (#). 53 22 15 82 29
22. Total payments ($). 1,575 963 732 7,346 1,803

2010–2011 2011–2012 2012–2013 2013–2014 2014–2015
23. Number of participating dentists (#). not available not available not available not available not available
24. Number of services provided (#). not available not available not available not available not available
2. Typically, Nunavut does not pay its physicians through fee-for-service. Instead, the majority of physicians are compensated through contracted salaries.
3. Fee-for-service is lower in 2014–2015 due to a new radiology contract.
4. For 2014–15 this is the amount as of August 2015. Bills are accepted until March 2016.

ANNEX A
CANADA HEALTH ACT AND

EXTRA-BILLING AND USER
CHARGES INFORMATION
REGULATIONS
This annex provides the reader with an office consolidation of and user charges prior to the beginning of each fiscal year so
the Canada Health Act and the Extra-billing and User Charges that appropriate penalties can be levied, as well as financial
Information Regulations. An office consolidation is a rendering statements showing the amounts actually charged so that
of the original Act, which includes any amendments that have reconciliations with any estimated charges can be made. These
been made since the Act’s passage. The only regulations in regulations are also presented in an office consolidation format.
force under the Act are the Extra-billing and User Charges This unofficial consolidation is current to July 8, 2012. It is
Information Regulations. These regulations require the provided for the convenience of the reader only. For the official
provinces and territories to provide estimates of extra-billing text of the Canada Health Act, please contact Justice Canada.

142 CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
CANADA
CANADA
CONSOLIDATION CODIFICATION
Canada Health Act Loi canadienne sur la

santé
R.S.C., 1985, c. C-6 L.R.C., 1985, ch. C-6
Current to July 8, 2012 À jour au 8 juillet 2012
Last amended on June 29, 2012 Dernière modification le 29 juin 2012
Published by the Minister of Justice at the following address: Publié par le ministre de la Justice à l’adresse suivante :
http://laws-lois.justice.gc.ca http://lois-laws.justice.gc.ca
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015 143

OFFICIAL STATUS CARACTÈRE OFFICIEL
OF CONSOLIDATIONS DES CODIFICATIONS
Subsections 31(1) and (2) of the Legislation Les paragraphes 31(1) et (2) de la Loi sur la
Revision and Consolidation Act, in force on révision et la codification des textes législatifs,
June 1, 2009, provide as follows: en vigueur le 1er juin 2009, prévoient ce qui
suit :
Published 31. (1) Every copy of a consolidated statute or 31. (1) Tout exemplaire d'une loi codifiée ou d'un Codifications
consolidation is consolidated regulation published by the Minister règlement codifié, publié par le ministre en vertu de comme élément
evidence under this Act in either print or electronic form is ev- la présente loi sur support papier ou sur support élec- de preuve
idence of that statute or regulation and of its contents tronique, fait foi de cette loi ou de ce règlement et de
and every copy purporting to be published by the son contenu. Tout exemplaire donné comme publié
Minister is deemed to be so published, unless the par le ministre est réputé avoir été ainsi publié, sauf
contrary is shown. preuve contraire.
Inconsistencies (2) In the event of an inconsistency between a (2) Les dispositions de la loi d'origine avec ses Incompatibilité
in Acts consolidated statute published by the Minister under modifications subséquentes par le greffier des Parle- — lois
this Act and the original statute or a subsequent ments en vertu de la Loi sur la publication des lois
amendment as certified by the Clerk of the Parlia- l'emportent sur les dispositions incompatibles de la
ments under the Publication of Statutes Act, the orig- loi codifiée publiée par le ministre en vertu de la pré-
inal statute or amendment prevails to the extent of sente loi.
the inconsistency.
NOTE NOTE
This consolidation is current to July 8, 2012. The last Cette codification est à jour au 8 juillet 2012. Les
amendments came into force on June 29, 2012. Any dernières modifications sont entrées en vigueur
amendments that were not in force as of July 8, 2012 le 29 juin 2012. Toutes modifications qui n'étaient
are set out at the end of this document under the pas en vigueur au 8 juillet 2012 sont énoncées à la
heading “Amendments Not in Force”. fin de ce 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 du

Canada and relating to criteria and Canada ainsi que les principes et
conditions in respect of insured health conditions applicables aux services de
services and extended health care services santé assurés et aux services
complémentaires de santé
Preamble WHEREAS the Parliament of Canada recog- Considérant que le Parlement du Canada re- Préambule
nizes: connaît :
—that it is not the intention of the Govern- que le gouvernement du Canada n’entend
ment of Canada that any of the powers, pas par la présente loi abroger les pouvoirs,
rights, privileges or authorities vested in droits, privilèges ou autorités dévolus au
Canada or the provinces under the provisions Canada ou aux provinces sous le régime de
of the Constitution Act, 1867, or any amend- la Loi constitutionnelle de 1867 et de ses mo-
ments thereto, or otherwise, be by reason of difications ou à tout autre titre, ni leur déro-
this Act abrogated or derogated from or in ger ou porter atteinte,
any way impaired;
que les Canadiens ont fait des progrès remar-
—that Canadians, through their system of in- quables, grâce à leur système de services de
sured health services, have made outstanding santé assurés, dans le traitement des maladies
progress in treating sickness and alleviating et le soulagement des affections et défi-
the consequences of disease and disability ciences parmi toutes les catégories socio-
among all income groups; économiques,
—that Canadians can achieve further im- que les Canadiens peuvent encore améliorer
provements in their well-being through com- leur bien-être en joignant à un mode de vie
bining individual lifestyles that emphasize individuel axé sur la condition physique, la
fitness, prevention of disease and health pro- prévention des maladies et la promotion de la
motion with collective action against the so- santé, une action collective contre les causes
cial, environmental and occupational causes sociales, environnementales ou industrielles
of disease, and that they desire a system of des maladies et qu’ils désirent un système de
health services that will promote physical services de santé qui favorise la santé phy-
and mental health and protection against dis- sique et mentale et la protection contre les
ease; maladies,
—that future improvements in health will re- que les améliorations futures dans le do-
quire the cooperative partnership of govern- maine de la santé nécessiteront la coopéra-
ments, health professionals, voluntary orga- tion des gouvernements, des professionnels
nizations and individual Canadians; de la santé, des organismes bénévoles et des
citoyens canadiens,
—that continued access to quality health care
without financial or other barriers will be que l’accès continu à des soins de santé de
critical to maintaining and improving the qualité, sans obstacle financier ou autre, sera
health and well-being of Canadians; déterminant pour la conservation et l’amélio-
ration de la santé et du bien-être des Cana-
diens;
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015 1 145

Canada Health — July 8, 2012
AND WHEREAS the Parliament of Canada considérant en outre que le Parlement du

wishes to encourage the development of health Canada souhaite favoriser le développement
services throughout Canada by assisting the des services de santé dans tout le pays en aidant
provinces in meeting the costs thereof; les provinces à en supporter le coût,
NOW, THEREFORE, Her Majesty, by and Sa Majesté, sur l’avis et avec le consentement
with the advice and consent of the Senate and du Sénat et de la Chambre des communes du
House of Commons of Canada, enacts as fol- Canada, édicte :
lows:
SHORT TITLE TITRE ABRÉGÉ

Short title 1. This Act may be cited as the Canada 1. Loi canadienne sur la santé. Titre abrégé
Health Act. 1984, ch. 6, art. 1.
1984, c. 6, s. 1.
INTERPRETATION DÉFINITIONS
Definitions 2. In this Act, 2. Les définitions qui suivent s’appliquent à Définitions
la présente loi.
“Act of 1977” [Repealed, 1995, c. 17, s. 34]
« assuré » Habitant d’une province, à l’excep- « assuré »
“cash “cash contribution” means the cash contribu- “insured
contribution”
tion in respect of the Canada Health Transfer tion : person”
« contribution
pécuniaire » that may be provided to a province under sec- a) des membres des Forces canadiennes;
tions 24.2 and 24.21 of the Federal-Provincial
b) [Abrogé, 2012, ch. 19, art. 377]
Fiscal Arrangements Act;
c) des personnes purgeant une peine d’em-
“contribution” [Repealed, 1995, c. 17, s. 34]
prisonnement dans un pénitencier, au sens de
“dentist” “dentist” means a person lawfully entitled to la Partie I de la Loi sur le système correc-
« dentiste »
practise dentistry in the place in which the tionnel et la mise en liberté sous condition;
practice is carried on by that person;
d) des habitants de la province qui s’y
“extended health “extended health care services” means the fol- trouvent depuis une période de temps infé-
care services”
« services
lowing services, as more particularly defined in rieure au délai minimal de résidence ou de
complémentaires the regulations, provided for residents of a carence d’au plus trois mois imposé aux ha-
de santé »
province, namely, bitants par la province pour qu’ils soient ad-
(a) nursing home intermediate care service, missibles ou aient droit aux services de santé
assurés.
(b) adult residential care service,
« contribution » [Abrogée, 1995, ch. 17, art. 34]
(c) home care service, and
« contribution pécuniaire » La contribution au « contribution
(d) ambulatory health care service; titre du Transfert canadien en matière de santé pécuniaire »
“cash
“extra-billing” “extra-billing” means the billing for an insured qui peut être versée à une province au titre des contribution”
« surfactura-
health service rendered to an insured person by articles 24.2 et 24.21 de la Loi sur les arrange-
tion »
a medical practitioner or a dentist in an amount ments fiscaux entre le gouvernement fédéral et
in addition to any amount paid or to be paid for les provinces.
that service by the health care insurance plan of « dentiste » Personne légalement autorisée à « dentiste »
a province; exercer la médecine dentaire au lieu où elle se “dentist”
“health care “health care insurance plan” means, in relation livre à cet exercice.
insurance plan”
« régime
to a province, a plan or plans established by the « frais modérateurs » Frais d’un service de santé « frais
d’assurance- law of the province to provide for insured assuré autorisés ou permis par un régime pro- modérateurs »
santé » “user charge”
health services; vincial d’assurance-santé mais non payables,

2
Santé — 8 juillet 2012
“health care “health care practitioner” means a person law- soit directement soit indirectement, au titre
practitioner”
« professionnel
fully entitled under the law of a province to d’un régime provincial d’assurance-santé, à
de la santé » provide health services in the place in which l’exception des frais imposés par surfactura-
the services are provided by that person; tion.
“hospital” “hospital” includes any facility or portion « habitant » Personne domiciliée et résidant ha- « habitant »
« hôpital » “resident”
thereof that provides hospital care, including bituellement dans une province et légalement
acute, rehabilitative or chronic care, but does autorisée à être ou à rester au Canada, à l’ex-
not include ception d’une personne faisant du tourisme, de
(a) a hospital or institution primarily for the passage ou en visite dans la province.
mentally disordered, or « hôpital » Sont compris parmi les hôpitaux tout « hôpital »
“hospital”
(b) a facility or portion thereof that provides ou partie des établissements où sont fournis des
soins hospitaliers, notamment aux personnes
nursing home intermediate care service or
souffrant de maladie aiguë ou chronique ainsi
adult residential care service, or comparable
qu’en matière de réadaptation, à l’exception :
services for children;
“hospital “hospital services” means any of the following a) des hôpitaux ou institutions destinés prin-
services”
services provided to in-patients or out-patients cipalement aux personnes souffrant de
« services troubles mentaux;
hospitaliers » at a hospital, if the services are medically nec-
essary for the purpose of maintaining health, b) de tout ou partie des établissements où
preventing disease or diagnosing or treating an sont fournis des soins intermédiaires en mai-
injury, illness or disability, namely, son de repos ou des soins en établissement
(a) accommodation and meals at the stan- pour adultes ou des soins comparables pour
dard or public ward level and preferred ac- les enfants.
commodation if medically required, « loi de 1977 » [Abrogée, 1995, ch. 17, art. 34]
(b) nursing service, « médecin » Personne légalement autorisée à « médecin »
“medical
(c) laboratory, radiological and other diag- exercer la médecine au lieu où elle se livre à cet practitioner”
nostic procedures, together with the neces- exercice.
sary interpretations, « ministre » Le ministre de la Santé. « ministre »
“Minister”
(d) drugs, biologicals and related prepara-
tions when administered in the hospital, « professionnel de la santé » Personne légale- « professionnel
de la santé »
ment autorisée en vertu de la loi d’une province “health care
(e) use of operating room, case room and à fournir des services de santé au lieu où elle practitioner”
anaesthetic facilities, including necessary les fournit.
equipment and supplies,
« régime d’assurance-santé » Le régime ou les « régime
(f) medical and surgical equipment and sup- régimes constitués par la loi d’une province en d’assurance-
santé »
plies, vue de la prestation de services de santé assu- “health care
insurance plan”
(g) use of radiotherapy facilities, rés.
(h) use of physiotherapy facilities, and « services complémentaires de santé » Les ser- « services
complémentaires
vices définis dans les règlements et offerts aux de santé »
(i) services provided by persons who receive habitants d’une province, à savoir : “extended health
remuneration therefor from the hospital, care services”
a) les soins intermédiaires en maison de re-
but does not include services that are excluded pos;
by the regulations;
b) les soins en établissement pour adultes;
“insured health “insured health services” means hospital ser-
services”
vices, physician services and surgical-dental c) les soins à domicile;
« services de
santé assurés » services provided to insured persons, but does d) les soins ambulatoires.
not include any health services that a person is
entitled to and eligible for under any other Act
of Parliament or under any Act of the legisla-

3
ture of a province that relates to workers' or « services de chirurgie dentaire » Actes de chi- « services de
chirurgie
workmen’s compensation; rurgie dentaire nécessaires sur le plan médical dentaire »
“insured person” “insured person” means, in relation to a ou dentaire, accomplis par un dentiste dans un “surgical-dental
services”
« assuré »
province, a resident of the province other than hôpital, et qui ne peuvent être accomplis conve-
nablement qu’en un tel établissement.
(a) a member of the Canadian Forces,
« services de santé assurés » Services hospita- « services de
(b) [Repealed, 2012, c. 19, s. 377] liers, médicaux ou de chirurgie dentaire fournis santé assurés »
“insured health
(c) a person serving a term of imprisonment aux assurés, à l’exception des services de santé services”
in a penitentiary as defined in the Peniten- auxquels une personne a droit ou est admissible
tiary Act, or en vertu d’une autre loi fédérale ou d’une loi
provinciale relative aux accidents du travail.
(d) a resident of the province who has not
completed such minimum period of resi- « services hospitaliers » Services fournis dans « services
hospitaliers »
dence or waiting period, not exceeding three un hôpital aux malades hospitalisés ou ex- “hospital
months, as may be required by the province ternes, si ces services sont médicalement néces- services”
for eligibility for or entitlement to insured saires pour le maintien de la santé, la préven-
health services; tion des maladies ou le diagnostic ou le
traitement des blessures, maladies ou invalidi-
“medical “medical practitioner” means a person lawfully tés, à savoir :
practitioner”
« médecin »
entitled to practise medicine in the place in
which the practice is carried on by that person; a) l’hébergement et la fourniture des repas
en salle commune ou, si médicalement né-
“Minister” “Minister” means the Minister of Health; cessaire, en chambre privée ou semi-privée;
« ministre »
“physician “physician services” means any medically re- b) les services infirmiers;
services”
« services
quired services rendered by medical practition- c) les actes de laboratoires, de radiologie ou
médicaux » ers; autres actes de diagnostic, ainsi que les inter-
“resident” “resident” means, in relation to a province, a prétations nécessaires;
« habitant »
person lawfully entitled to be or to remain in d) les produits pharmaceutiques, substances
Canada who makes his home and is ordinarily biologiques et préparations connexes admi-
present in the province, but does not include a nistrés à l’hôpital;
tourist, a transient or a visitor to the province;
e) l’usage des salles d’opération, des salles
“surgical-dental “surgical-dental services” means any medically d’accouchement et des installations d’anes-
services”
« services de
or dentally required surgical-dental procedures thésie, ainsi que le matériel et les fournitures
chirurgie performed by a dentist in a hospital, where a nécessaires;
dentaire »
hospital is required for the proper performance
of the procedures; f) le matériel et les fournitures médicaux et
chirurgicaux;
“user charge” “user charge” means any charge for an insured
« frais
health service that is authorized or permitted by g) l’usage des installations de radiothérapie;
modérateurs »
a provincial health care insurance plan that is h) l’usage des installations de physiothéra-
not payable, directly or indirectly, by a provin- pie;
cial health care insurance plan, but does not in-
clude any charge imposed by extra-billing. i) les services fournis par les personnes ré-
munérées à cet effet par l’hôpital.
R.S., 1985, c. C-6, s. 2; 1992, c. 20, s. 216(F); 1995, c. 17,
s. 34; 1996, c. 8, s. 32; 1999, c. 26, s. 11; 2012, c. 19, ss. Ne sont pas compris parmi les services hospita-
377, 407.
liers les services exclus par les règlements.
« services médicaux » Services médicalement « services
médicaux »
nécessaires fournis par un médecin. “physician
services”
« surfacturation » Facturation de la prestation à « surfactura-

tion »
un assuré par un médecin ou un dentiste d’un “extra-billing”

4
service de santé assuré, en excédent par rapport

au montant payé ou à payer pour la prestation
de ce service au titre du régime provincial d’as-
surance-santé.
L.R. (1985), ch. C-6, art. 2; 1992, ch. 20, art. 216(F); 1995,
ch. 17, art. 34; 1996, ch. 8, art. 32; 1999, ch. 26, art. 11;
2012, ch. 19, art. 377 et 407.
CANADIAN HEALTH CARE POLICY POLITIQUE CANADIENNE DE LA SANTÉ

Primary 3. It is hereby declared that the primary ob- 3. La politique canadienne de la santé a pour Objectif premier
objective of
Canadian health
jective of Canadian health care policy is to pro- premier objectif de protéger, de favoriser et
care policy tect, promote and restore the physical and men- d’améliorer le bien-être physique et mental des
tal well-being of residents of Canada and to habitants du Canada et de faciliter un accès sa-
facilitate reasonable access to health services tisfaisant aux services de santé, sans obstacles
without financial or other barriers. d’ordre financier ou autre.
1984, c. 6, s. 3. 1984, ch. 6, art. 3.
PURPOSE RAISON D’ÊTRE

Purpose of this 4. The purpose of this Act is to establish cri- 4. La présente loi a pour raison d’être d’éta- Raison d’être de
Act la présente loi
teria and conditions in respect of insured health blir les conditions d’octroi et de versement
services and extended health care services pro- d’une pleine contribution pécuniaire pour les
vided under provincial law that must be met be- services de santé assurés et les services complé-
fore a full cash contribution may be made. mentaires 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 5. Subject to this Act, as part of the Canada 5. Sous réserve des autres dispositions de la Contribution
contribution pécuniaire
Health Transfer, a full cash contribution is présente loi, le Canada verse à chaque pro-
payable by Canada to each province for each vince, pour chaque exercice, une pleine contri-
fiscal year. bution pécuniaire à titre d’élément du Transfert
R.S., 1985, c. C-6, s. 5; 1995, c. 17, s. 36; 2012, c. 19, s. canadien en matière de santé (ci-après, « Trans-
408. fert »).
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 7. In order that a province may qualify for a 7. Le versement à une province, pour un Règle générale
full cash contribution referred to in section 5 exercice, de la pleine contribution pécuniaire
for a fiscal year, the health care insurance plan visée à l’article 5 est assujetti à l’obligation
of the province must, throughout the fiscal pour le régime d’assurance-santé de satisfaire,
year, satisfy the criteria described in sections 8 pendant tout cet exercice, aux conditions d’oc-
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;

5
(e) accessibility. e) l’accessibilité.
1984, c. 6, s. 7. 1984, ch. 6, art. 7.
Public 8. (1) In order to satisfy the criterion re- 8. (1) La condition de gestion publique sup- Gestion
administration publique
specting public administration, pose que :
(a) the health care insurance plan of a a) le régime provincial d’assurance-santé
province must be administered and operated soit géré sans but lucratif par une autorité pu-
on a non-profit basis by a public authority blique nommée ou désignée par le gouverne-
appointed or designated by the government ment de la province;
of the province;
b) l’autorité publique soit responsable de-
(b) the public authority must be responsible vant le gouvernement provincial de cette
to the provincial government for that admin- gestion;
istration and operation; and
c) l’autorité publique soit assujettie à la véri-
(c) the public authority must be subject to fication de ses comptes et de ses opérations
audit of its accounts and financial transac- financières par l’autorité chargée par la loi de
tions by such authority as is charged by law la vérification des comptes de la province.
with the audit of the accounts of the
province.
Designation of (2) The criterion respecting public adminis- (2) La condition de gestion publique n’est Désignation
agency d’un mandataire
permitted
tration is not contravened by reason only that pas enfreinte du seul fait que l’autorité publique
the public authority referred to in subsection (1) visée au paragraphe (1) a le pouvoir de dési-
has the power to designate any agency gner un mandataire chargé :
(a) to receive on its behalf any amounts a) soit de recevoir en son nom les montants
payable under the provincial health care in- payables au titre du régime provincial d’as-
surance plan; or surance-santé;
(b) to carry out on its behalf any responsibil- b) soit d’exercer en son nom les attributions
ity in connection with the receipt or payment liées à la réception ou au règlement des
of accounts rendered for insured health ser- comptes remis pour prestation de services de
vices, if it is a condition of the designation santé assurés si la désignation est assujettie à
that all those accounts are subject to assess- la vérification et à l’approbation par l’autori-
ment and approval by the public authority té publique des comptes ainsi remis et à la
and that the public authority shall determine détermination par celle-ci des montants à
the amounts to be paid in respect thereof. payer à cet égard.
1984, c. 6, s. 8. 1984, ch. 6, art. 8.
Comprehensive- 9. In order to satisfy the criterion respecting 9. La condition d’intégralité suppose qu’au Intégralité
ness
comprehensiveness, the health care insurance titre du régime provincial d’assurance-santé,
plan of a province must insure all insured tous les services de santé assurés fournis par les
health services provided by hospitals, medical hôpitaux, les médecins ou les dentistes soient
practitioners or dentists, and where the law of assurés, et lorsque la loi de la province le per-
the province so permits, similar or additional met, les services semblables ou additionnels
services rendered by other health care practi- fournis par les autres professionnels de la santé.
tioners. 1984, ch. 6, art. 9.
1984, c. 6, s. 9.
Universality 10. In order to satisfy the criterion respect- 10. La condition d’universalité suppose Universalité
ing universality, the health care insurance plan qu’au titre du régime provincial d’assurance-
of a province must entitle one hundred per cent santé, cent pour cent des assurés de la province
of the insured persons of the province to the in- ait droit aux services de santé assurés prévus
par celui-ci, selon des modalités uniformes.
1984, ch. 6, art. 10.

6
sured health services provided for by the plan

on uniform terms and conditions.
1984, c. 6, s. 10.
Portability 11. (1) In order to satisfy the criterion re- 11. (1) La condition de transférabilité sup- Transférabilité
specting portability, the health care insurance pose que le régime provincial d’assurance-
plan of a province santé :
(a) must not impose any minimum period of a) n’impose pas de délai minimal de rési-
residence in the province, or waiting period, dence ou de carence supérieur à trois mois
in excess of three months before residents of aux habitants de la province pour qu’ils
the province are eligible for or entitled to in- soient admissibles ou aient droit aux services
sured health services; de santé assurés;
(b) must provide for and be administered b) prévoie et que ses modalités d’application
and operated so as to provide for the pay- assurent le paiement des montants pour le
ment of amounts for the cost of insured coût des services de santé assurés fournis à
health services provided to insured persons des assurés temporairement absents de la
while temporarily absent from the province province :
on the basis that
(i) si ces services sont fournis au Canada,
(i) where the insured health services are selon le taux approuvé par le régime d’as-
provided in Canada, payment for health surance-santé de la province où ils sont
services is at the rate that is approved by fournis, sauf accord de répartition diffé-
the health care insurance plan of the rente du coût entre les provinces concer-
province in which the services are provid- nées,
ed, unless the provinces concerned agree
(ii) s’il sont fournis à l’étranger, selon le
to apportion the cost between them in a
montant qu’aurait versé la province pour
different manner, or
des services semblables fournis dans la
(ii) where the insured health services are province, compte tenu, s’il s’agit de ser-
provided out of Canada, payment is made vices hospitaliers, de l’importance de l’hô-
on the basis of the amount that would have pital, de la qualité des services et des
been paid by the province for similar ser- autres facteurs utiles;
vices rendered in the province, with due
c) prévoie et que ses modalités d’application
regard, in the case of hospital services, to
assurent la prise en charge, pendant le délai
the size of the hospital, standards of ser-
minimal de résidence ou de carence imposé
vice and other relevant factors; and
par le régime d’assurance-santé d’une autre
(c) must provide for and be administered province, du coût des services de santé assu-
and operated so as to provide for the pay- rés fournis aux personnes qui ne sont plus as-
ment, during any minimum period of resi- surées du fait qu’elles habitent cette pro-
dence, or any waiting period, imposed by the vince, dans les mêmes conditions que si elles
health care insurance plan of another habitaient encore leur province d’origine.
province, of the cost of insured health ser-
vices provided to persons who have ceased
to be insured persons by reason of having be-
come residents of that other province, on the
same basis as though they had not ceased to
be residents of the province.
Requirement for (2) The criterion respecting portability is not (2) La condition de transférabilité n’est pas Consentement
consent for préalable à la
elective insured
contravened by a requirement of a provincial enfreinte du fait qu’il faut, aux termes du ré- prestation des
health services health care insurance plan that the prior consent gime d’assurance-santé d’une province, le services de santé
permitted assurés
of the public authority that administers and op- consentement préalable de l’autorité publique facultatifs
erates the plan must be obtained for elective in- qui le gère pour la prestation de services de

7
sured health services provided to a resident of santé assurés facultatifs à un habitant temporai-
the province while temporarily absent from the rement absent de la province, si ces services y
province if the services in question were avail- sont offerts selon des modalités sensiblement
able on a substantially similar basis in the comparables.
province.
Definition of (3) For the purpose of subsection (2), “elec- (3) Pour l’application du paragraphe (2), Définition de
"elective insured « services de
health services"
tive insured health services” means insured « services de santé assurés facultatifs » s’entend santé assurés
health services other than services that are pro- des services de santé assurés, à l’exception de facultatifs »
vided in an emergency or in any other circum- ceux qui sont fournis d’urgence ou dans
stance in which medical care is required with- d’autres circonstances où des soins médicaux
out delay. sont requis sans délai.
1984, c. 6, s. 11. 1984, ch. 6, art. 11.
Accessibility 12. (1) In order to satisfy the criterion re- 12. (1) La condition d’accessibilité suppose Accessibilité
specting accessibility, the health care insurance que le régime provincial d’assurance-santé :
plan of a province
a) offre les services de santé assurés selon
(a) must provide for insured health services des modalités uniformes et ne fasse pas obs-
on uniform terms and conditions and on a tacle, directement ou indirectement, et no-
basis that does not impede or preclude, either tamment par facturation aux assurés, à un ac-
directly or indirectly whether by charges cès satisfaisant par eux à ces services;
made to insured persons or otherwise, rea-
b) prévoie la prise en charge des services de
sonable access to those services by insured
santé assurés selon un tarif ou autre mode de
persons;
paiement autorisé par la loi de la province;
(b) must provide for payment for insured
c) prévoie une rémunération raisonnable de
health services in accordance with a tariff or
tous les services de santé assurés fournis par
system of payment authorized by the law of
les médecins ou les dentistes;
the province;
d) prévoie le versement de montants aux hô-
(c) must provide for reasonable compensa-
pitaux, y compris les hôpitaux que possède
tion for all insured health services rendered
ou gère le Canada, à l’égard du coût des ser-
by medical practitioners or dentists; and
vices de santé assurés.
(d) must provide for the payment of
amounts to hospitals, including hospitals
owned or operated by Canada, in respect of
the cost of insured health services.
Reasonable (2) In respect of any province in which ex- (2) Pour toute province où la surfacturation Rémunération
compensation raisonnable
tra-billing is not permitted, paragraph (1)(c) n’est pas permise, il est réputé être satisfait à
shall be deemed to be complied with if the l’alinéa (1)c) si la province a choisi de conclure
province has chosen to enter into, and has en- un accord et a effectivement conclu un accord
tered into, an agreement with the medical prac- avec ses médecins et dentistes prévoyant :
titioners and dentists of the province that pro-
a) la tenue de négociations sur la rémunéra-
vides
tion des services de santé assurés entre la
(a) for negotiations relating to compensation province et les organisations provinciales re-
for insured health services between the présentant les médecins ou dentistes qui
province and provincial organizations that exercent dans la province;
represent practising medical practitioners or
b) le règlement des différends concernant la
dentists in the province;
rémunération par, au choix des organisations
(b) for the settlement of disputes relating to provinciales compétentes visées à l’alinéa a),
compensation through, at the option of the soit la conciliation soit l’arbitrage obligatoire
appropriate provincial organizations referred par un groupe représentant également les or-
8
to in paragraph (a), conciliation or binding ganisations provinciales et la province et

arbitration by a panel that is equally repre- ayant un président indépendant;
sentative of the provincial organizations and
c) l’impossibilité de modifier la décision du
the province and that has an independent
groupe visé à l’alinéa b), sauf par une loi de
chairman; and
la province.
(c) that a decision of a panel referred to in 1984, ch. 6, art. 12.
paragraph (b) may not be altered except by
an Act of the legislature of the province.
1984, c. 6, s. 12.
CONDITIONS FOR CASH CONTRIBUTION CONTRIBUTION PÉCUNIAIRE

ASSUJETTIE À DES CONDITIONS
Conditions 13. In order that a province may qualify for 13. Le versement à une province de la pleine Obligations de la
province
a full cash contribution referred to in section 5, contribution pécuniaire visée à l’article 5 est as-
the government of the province sujetti à l’obligation pour le gouvernement de
la province :
(a) shall, at the times and in the manner pre-
scribed by the regulations, provide the Min- a) de communiquer au ministre, selon les
ister with such information, of a type pre- modalités de temps et autres prévues par les
scribed by the regulations, as the Minister règlements, les renseignements du genre pré-
may reasonably require for the purposes of vu aux règlements, dont celui-ci peut norma-
this Act; and lement avoir besoin pour l’application de la
(b) shall give recognition to the Canada présente loi;
Health Transfer in any public documents, or b) de faire état du Transfert dans tout docu-
in any advertising or promotional material, ment public ou toute publicité sur les ser-
relating to insured health services and ex- vices de santé assurés et les services complé-
tended health care services in the province. mentaires de santé dans la province.
R.S., 1985, c. C-6, s. 13; 1995, c. 17, s. 37; 2012, c. 19, s. L.R. (1985), ch. C-6, art. 13; 1995, ch. 17, art. 37; 2012, ch.
409(E). 19, art. 409(A).
DEFAULTS MANQUEMENTS
Referral to 14. (1) Subject to subsection (3), where the 14. (1) Sous réserve du paragraphe (3), dans Renvoi au
Governor in gouverneur en
Council
Minister, after consultation in accordance with le cas où il estime, après avoir consulté confor- conseil
subsection (2) with the minister responsible for mément au paragraphe (2) son homologue
health care in a province, is of the opinion that chargé de la santé dans une province :
(a) the health care insurance plan of the a) soit que le régime d’assurance-santé de la
province does not or has ceased to satisfy province ne satisfait pas ou plus aux condi-
any one of the criteria described in sections 8 tions visées aux articles 8 à 12;
to 12, or
b) soit que la province ne s’est pas confor-
(b) the province has failed to comply with mée aux conditions visées à l’article 13,
any condition set out in section 13,
et que celle-ci ne s’est pas engagée de façon sa-
and the province has not given an undertaking tisfaisante à remédier à la situation dans un dé-
satisfactory to the Minister to remedy the de- lai suffisant, le ministre renvoie l’affaire au
fault within a period that the Minister considers gouverneur en conseil.
reasonable, the Minister shall refer the matter
to the Governor in Council.
Consultation (2) Before referring a matter to the Gover- (2) Avant de renvoyer une affaire au gou- Étapes de la
process consultation
nor in Council under subsection (1) in respect verneur en conseil conformément au para-
of a province, the Minister shall graphe (1) relativement à une province, le mi-
nistre :

9
(a) send by registered mail to the minister a) envoie par courrier recommandé à son
responsible for health care in the province a homologue chargé de la santé dans la pro-
notice of concern with respect to any prob- vince un avis sur tout problème éventuel;
lem foreseen;
b) tente d’obtenir de la province, par discus-
(b) seek any additional information avail- sions bilatérales, tout renseignement addi-
able from the province with respect to the tionnel disponible sur le problème et fait rap-
problem through bilateral discussions, and port à la province dans les quatre-vingt-dix
make a report to the province within ninety jours suivant l’envoi de l’avis;
days after sending the notice of concern; and
c) si la province le lui demande, tient une
(c) if requested by the province, meet within réunion dans un délai acceptable afin de dis-
a reasonable period of time to discuss the re- cuter du rapport.
port.
Where no (3) The Minister may act without consulta- (3) Le ministre peut procéder au renvoi pré- Impossibilité de
consultation can consultation
be achieved
tion under subsection (1) if the Minister is of vu au paragraphe (1) sans consultation préa-
the opinion that a sufficient time has expired lable s’il conclut à l’impossibilité d’obtenir
after reasonable efforts to achieve consultation cette consultation malgré des efforts sérieux dé-
and that consultation will not be achieved. ployés à cette fin au cours d’un délai conve-
1984, c. 6, s. 14. nable.
1984, ch. 6, art. 14.
Order reducing 15. (1) Where, on the referral of a matter 15. (1) Si l’affaire lui est renvoyée en vertu Décret de
or withholding réduction ou de
contribution
under section 14, the Governor in Council is of de l’article 14 et qu’il estime que le régime retenue
the opinion that the health care insurance plan d’assurance-santé de la province ne satisfait pas
of a province does not or has ceased to satisfy ou plus aux conditions visées aux articles 8 à
any one of the criteria described in sections 8 to 12 ou que la province ne s’est pas conformée
12 or that a province has failed to comply with aux conditions visées à l’article 13, le gouver-
any condition set out in section 13, the Gover- neur en conseil peut, par décret :
nor in Council may, by order,
a) soit ordonner, pour chaque manquement,
(a) direct that any cash contribution to that que la contribution pécuniaire d’un exercice
province for a fiscal year be reduced, in re- à la province soit réduite du montant qu’il
spect of each default, by an amount that the estime indiqué, compte tenu de la gravité du
Governor in Council considers to be appro- manquement;
priate, having regard to the gravity of the de-
b) soit, s’il l’estime indiqué, ordonner la re-
fault; or
tenue de la totalité de la contribution pécu-
(b) where the Governor in Council considers niaire d’un exercice à la province.
it appropriate, direct that the whole of any
cash contribution to that province for a fiscal
year be withheld.
Amending (2) The Governor in Council may, by order, (2) Le gouverneur en conseil peut, par dé- Modification des
orders décrets
repeal or amend any order made under subsec- cret, annuler ou modifier un décret pris en vertu
tion (1) where the Governor in Council is of the du paragraphe (1) s’il l’estime justifié dans les
opinion that the repeal or amendment is war- circonstances.
ranted in the circumstances.
Notice of order (3) A copy of each order made under this (3) Le texte de chaque décret pris en vertu Avis
section together with a statement of any find- du présent article de même qu’un exposé des
ings on which the order was based shall be sent motifs sur lesquels il est fondé sont envoyés
forthwith by registered mail to the government sans délai par courrier recommandé au gouver-
of the province concerned and the Minister nement de la province concernée; le ministre
shall cause the order and statement to be laid fait déposer le texte du décret et celui de l’ex-
before each House of Parliament on any of the posé devant chaque chambre du Parlement dans

10
first fifteen days on which that House is sitting les quinze premiers jours de séance de celle-ci
after the order is made. suivant la prise du décret.
Commencement (4) An order made under subsection (1) (4) Un décret pris en vertu du paragraphe (1) Entrée en
of order vigueur du
shall not come into force earlier than thirty ne peut entrer en vigueur que trente jours après décret
days after a copy of the order has been sent to l’envoi au gouvernement de la province concer-
the government of the province concerned un- née du texte du décret aux termes du para-
der subsection (3). graphe (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 16. In the case of a continuing failure to sat- 16. En cas de manquement continu aux Nouvelle
reductions or application des
withholdings
isfy any of the criteria described in sections 8 to conditions visées aux articles 8 à 12 ou à l’ar- réductions ou
12 or to comply with any condition set out in ticle 13, les réductions ou retenues de la contri- retenues
section 13, any reduction or withholding under bution pécuniaire à une province déjà appli-
section 15 of a cash contribution to a province quées pour un exercice en vertu de l’article 15
for a fiscal year shall be reimposed for each lui sont appliquées de nouveau pour chaque
succeeding fiscal year as long as the Minister is exercice ultérieur où le ministre estime, après
satisfied, after consultation with the minister re- consultation de son homologue chargé de la
sponsible for health care in the province, that santé dans la province, que le manquement se
the default is continuing. continue.
When reduction 17. Any reduction or withholding under sec- 17. Toute réduction ou retenue d’une contri- Application aux
or withholding exercices
imposed
tion 15 or 16 of a cash contribution may be im- bution pécuniaire visée aux articles 15 ou 16 ultérieurs
posed in the fiscal year in which the default that peut être appliquée pour l’exercice où le man-
gave rise to the reduction or withholding oc- quement à son origine a eu lieu ou pour l’exer-
curred or in the following fiscal year. cice suivant.
EXTRA-BILLING AND USER CHARGES SURFACTURATION ET FRAIS

MODÉRATEURS
Extra-billing 18. In order that a province may qualify for 18. Une province n’a droit, pour un exer- Surfacturation
a full cash contribution referred to in section 5 cice, à la pleine contribution pécuniaire visée à
for a fiscal year, no payments may be permitted l’article 5 que si, aux termes de son régime
by the province for that fiscal year under the d’assurance-santé, elle ne permet pas pour cet
health care insurance plan of the province in re- exercice le versement de montants à l’égard des
spect of insured health services that have been services de santé assurés qui ont fait l’objet de
subject to extra-billing by medical practitioners surfacturation par les médecins ou les dentistes.
or dentists. 1984, ch. 6, art. 18.
1984, c. 6, s. 18.
User charges 19. (1) In order that a province may qualify 19. (1) Une province n’a droit, pour un Frais
modérateurs
for a full cash contribution referred to in sec- exercice, à la pleine contribution pécuniaire vi-
tion 5 for a fiscal year, user charges must not be sée à l’article 5 que si, aux termes de son ré-
permitted by the province for that fiscal year gime d’assurance-santé, elle ne permet pour cet
under the health care insurance plan of the exercice l’imposition d’aucuns frais modéra-
province. teurs.
Limitation (2) Subsection (1) does not apply in respect (2) Le paragraphe (1) ne s’applique pas aux Réserve
of user charges for accommodation or meals frais modérateurs imposés pour l’hébergement
provided to an in-patient who, in the opinion of ou les repas fournis à une personne hospitalisée
the attending physician, requires chronic care qui, de l’avis du médecin traitant, souffre d’une
and is more or less permanently resident in a maladie chronique et séjourne de façon plus ou
hospital or other institution.
1984, c. 6, s. 19.

11
moins permanente à l’hôpital ou dans une autre

institution.
1984, ch. 6, art. 19.
Deduction for 20. (1) Where a province fails to comply 20. (1) Dans le cas où une province ne se Déduction en
extra-billing cas de
with the condition set out in section 18, there conforme pas à la condition visée à l’article 18, surfacturation
shall be deducted from the cash contribution to il est déduit de la contribution pécuniaire à
the province for a fiscal year an amount that the cette dernière pour un exercice un montant, dé-
Minister, on the basis of information provided terminé par le ministre d’après les renseigne-
in accordance with the regulations, determines ments fournis conformément aux règlements,
to have been charged through extra-billing by égal au total de la surfacturation effectuée par
medical practitioners or dentists in the province les médecins ou les dentistes dans la province
in that fiscal year or, where information is not pendant l’exercice ou, si les renseignements
provided in accordance with the regulations, an n’ont pas été fournis conformément aux règle-
amount that the Minister estimates to have been ments, un montant estimé par le ministre égal à
so charged. ce total.
Deduction for (2) Where a province fails to comply with (2) Dans le cas où une province ne se Déduction en
user charges cas de frais
the condition set out in section 19, there shall conforme pas à la condition visée à l’article 19, modérateurs
be deducted from the cash contribution to the il est déduit de la contribution pécuniaire à
province for a fiscal year an amount that the cette dernière pour un exercice un montant, dé-
Minister, on the basis of information provided terminé par le ministre d’après les renseigne-
in accordance with the regulations, determines ments fournis conformément aux règlements,
to have been charged in the province in respect égal au total des frais modérateurs assujettis à
of user charges to which section 19 applies in l’article 19 imposés dans la province pendant
that fiscal year or, where information is not l’exercice ou, si les renseignements n’ont pas
provided in accordance with the regulations, an été fournis conformément aux règlements, un
amount that the Minister estimates to have been montant estimé par le ministre égal à ce total.
so charged.
Consultation (3) The Minister shall not estimate an (3) Avant d’estimer un montant visé au pa- Consultation de
with province la province
amount under subsection (1) or (2) without first ragraphe (1) ou (2), le ministre se charge de
undertaking to consult the minister responsible consulter son homologue responsable de la san-
for health care in the province concerned. té dans la province concernée.
Separate (4) Any amount deducted under subsection (4) Les montants déduits d’une contribution Comptabilisa-
accounting in tion
Public Accounts
(1) or (2) from a cash contribution in any of the pécuniaire en vertu des paragraphes (1) ou (2)
three consecutive fiscal years the first of which pendant les trois exercices consécutifs dont le
commences on April 1, 1984 shall be account- premier commence le 1er avril 1984 sont comp-
ed for separately in respect of each province in tabilisés séparément pour chaque province dans
the Public Accounts for each of those fiscal les comptes publics pour chacun de ces exer-
years in and after which the amount is deduct- cices pendant et après lequel le montant a été
ed. déduit.
Refund to (5) Where, in any of the three fiscal years (5) Si, de l’avis du ministre, la surfactura- Remboursement
province à la province
referred to in subsection (4), extra-billing or us- tion ou les frais modérateurs ont été supprimés
er charges have, in the opinion of the Minister, dans une province pendant l’un des trois exer-
been eliminated in a province, the total amount cices visés au paragraphe (4), il est versé à cette
deducted in respect of extra-billing or user dernière le montant total déduit à l’égard de la
charges, as the case may be, shall be paid to the surfacturation ou des frais modérateurs, selon le
province. cas.
Saving (6) Nothing in this section restricts the pow- (6) Le présent article n’a pas pour effet de Réserve
er of the Governor in Council to make any or- limiter le pouvoir du gouverneur en conseil de
der under section 15. prendre le décret prévu à l’article 15.
1984, c. 6, s. 20. 1984, ch. 6, art. 20.
156 12
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015
When deduction 21. Any deduction from a cash contribution 21. Toute déduction d’une contribution pé- Application aux
made exercices
under section 20 may be made in the fiscal year cuniaire visée à l’article 20 peut être appliquée ultérieurs
in which the matter that gave rise to the deduc- pour l’exercice où le fait à son origine a eu lieu
tion occurred or in the following two fiscal ou pour les deux exercices suivants.
years. 1984, ch. 6, art. 21.
1984, c. 6, s. 21.
REGULATIONS RÈGLEMENTS
Regulations 22. (1) Subject to this section, the Governor 22. (1) Sous réserve des autres dispositions Règlements
in Council may make regulations for the ad- du présent article, le gouverneur en conseil
ministration of this Act and for carrying its pur- peut, par règlement, prendre toute mesure d’ap-
poses and provisions into effect, including, plication de la présente loi et, notamment :
without restricting the generality of the forego-
a) définir les services visés aux alinéas a) à
ing, regulations
d) de la définition de « services complémen-
(a) defining the services referred to in para- taires de santé » à l’article 2;
graphs (a) to (d) of the definition "extended
b) déterminer les services exclus des ser-
health care services" in section 2;
vices hospitaliers;
(b) prescribing the services excluded from
c) déterminer les genres de renseignements
hospital services;
dont peut avoir besoin le ministre en vertu de
(c) prescribing the types of information that l’alinéa 13a) et fixer les modalités de temps
the Minister may require under paragraph et autres de leur communication;
13(a) and the times at which and the manner
d) prévoir la façon dont il doit être fait état
in which that information shall be provided;
du Transfert en vertu de l’alinéa 13b).
and
(d) prescribing the manner in which recogni-
tion to the Canada Health Transfer is re-
quired to be given under paragraph 13(b).
Agreement of (2) Subject to subsection (3), no regulation (2) Sous réserve du paragraphe (3), il ne Consentement
provinces des provinces
may be made under paragraph (1)(a) or (b) ex- peut être pris de règlements en vertu des alinéas
cept with the agreement of each of the (1)a) ou b) qu’avec l’accord de chaque pro-
provinces. vince.
Exception (3) Subsection (2) does not apply in respect (3) Le paragraphe (2) ne s’applique pas aux Exception
of regulations made under paragraph (1)(a) if règlements pris en vertu de l’alinéa (1)a) s’ils
they are substantially the same as regulations sont sensiblement comparables aux règlements
made under the Federal-Provincial Fiscal Ar- pris en vertu de la Loi sur les arrangements fis-
rangements Act, as it read immediately before caux entre le gouvernement fédéral et les pro-
April 1, 1984. vinces, dans sa version précédant immédiate-
ment le 1er avril 1984.
Consultation (4) No regulation may be made under para- (4) Il ne peut être pris de règlements en ver- Consultation des
with provinces provinces
graph (1)(c) or (d) unless the Minister has first tu des alinéas (1)c) ou d) que si le ministre a au
consulted with the ministers responsible for préalable consulté ses homologues chargés de
health care in the provinces. la santé dans les provinces.
R.S., 1985, c. C-6, s. 22; 1995, c. 17, s. 40; 2012, c. 19, s. L.R. (1985), ch. C-6, art. 22; 1995, ch. 17, art. 40; 2012, ch.
410(E). 19, art. 410(A).
REPORT TO PARLIAMENT RAPPORT AU PARLEMENT

Annual report by 23. The Minister shall, as soon as possible 23. Au plus tard pour le 31 décembre de Rapport annuel
Minister du ministre
after the termination of each fiscal year and in chaque année, le ministre établit dans les
any event not later than December 31 of the meilleurs délais un rapport sur l’application de

13
next fiscal year, make a report respecting the la présente loi au cours du précédent exercice,
administration and operation of this Act for that en y incluant notamment tous les renseigne-
fiscal year, including all relevant information ments pertinents sur la mesure dans laquelle les
on the extent to which provincial health care in- régimes provinciaux d’assurance-santé et les
surance plans have satisfied the criteria, and the provinces ont satisfait aux conditions d’octroi
extent to which the provinces have satisfied the et de versement prévues à la présente loi; le mi-
conditions, for payment under this Act and nistre fait déposer le rapport devant chaque
shall cause the report to be laid before each chambre du Parlement dans les quinze premiers
House of Parliament on any of the first fifteen jours de séance de celle-ci suivant son achève-
days on which that House is sitting after the rement.
port is completed. 1984, ch. 6, art. 23.
1984, c. 6, s. 23.

14
CANADA
CANADA
CONSOLIDATION CODIFICATION
Extra-billing and User Règlement concernant les

Charges Information renseignements sur la
Regulations surfacturation et les frais
modérateurs
SOR/86-259 DORS/86-259
Current to November 30, 2010 À jour au 30 novembre 2010
Published by the Minister of Justice at the following address: Publié par le ministre de la Justice à l’adresse suivante :
http://laws-lois.justice.gc.ca http://lois-laws.justice.gc.ca

OFFICIAL STATUS CARACTÈRE OFFICIEL
OF CONSOLIDATIONS DES CODIFICATIONS
Subsections 31(1) and (3) of the Legislation Les paragraphes 31(1) et (3) de la Loi sur la
Revision and Consolidation Act, in force on révision et la codification des textes législatifs,
June 1, 2009, provide as follows: en vigueur le 1er juin 2009, prévoient ce qui
suit :
Published 31. (1) Every copy of a consolidated statute or 31. (1) Tout exemplaire d'une loi codifiée ou Codifications
consolidation is consolidated regulation published by the Minister d'un règlement codifié, publié par le ministre en ver- comme élément
evidence under this Act in either print or electronic form is ev- tu de la présente loi sur support papier ou sur support de preuve
idence of that statute or regulation and of its contents électronique, fait foi de cette loi ou de ce règlement
and every copy purporting to be published by the et de son contenu. Tout exemplaire donné comme
Minister is deemed to be so published, unless the publié par le ministre est réputé avoir été ainsi pu-
contrary is shown. blié, sauf preuve contraire.
... [...]
Inconsistencies (3) In the event of an inconsistency between a (3) Les dispositions du règlement d'origine avec Incompatibilité
in regulations consolidated regulation published by the Minister ses modifications subséquentes enregistrées par le — règlements
under this Act and the original regulation or a subse- greffier du Conseil privé en vertu de la Loi sur les
quent amendment as registered by the Clerk of the textes réglementaires l'emportent sur les dispositions
Privy Council under the Statutory Instruments Act, incompatibles du règlement codifié publié par le mi-
the original regulation or amendment prevails to the nistre en vertu de la présente loi.
extent of the inconsistency.

REGULATIONS PRESCRIBING THE TYPES OF RÈGLEMENT DÉTERMINANT LES GENRES DE
INFORMATION THAT THE MINISTER OF RENSEIGNEMENTS DONT PEUT AVOIR
NATIONAL HEALTH AND WELFARE MAY BESOIN LE MINISTRE DE LA SANTÉ
REQUIRE UNDER PARAGRAPH 13(A) OF THE NATIONALE ET DU BIEN-ÊTRE SOCIAL EN
CANADA HEALTH ACT IN RESPECT OF VERTU DE L’ALINÉA 13A) DE LA LOI
EXTRA-BILLING AND USER CHARGES AND CANADIENNE SUR LA SANTÉ QUANT À LA
THE TIMES AT WHICH AND THE MANNER SURFACTURATION ET AUX FRAIS
IN WHICH SUCH INFORMATION SHALL BE MODÉRATEURS ET FIXANT LES
PROVIDED BY THE GOVERNMENT OF EACH MODALITÉS DE TEMPS ET LES AUTRES
PROVINCE MODALITÉS DE LEUR COMMUNICATION
PAR LE GOUVERNEMENT DE CHAQUE
PROVINCE
SHORT TITLE TITRE ABRÉGÉ

1. These Regulations may be cited as the Extra- 1. Règlement concernant les renseignements sur la
billing and User Charges Information Regulations. surfacturation et les frais modérateurs.
INTERPRETATION DÉFINITIONS
2. In these Regulations, 2. Les définitions qui suivent s’appliquent au présent
“Act” means the Canada Health Act; (Loi) règlement.
“Minister” means the Minister of National Health and « exercice » La période commençant le 1er avril d’une an-
Welfare; (ministre) née et se terminant le 31 mars de l’année suivante. (fiscal
year)
“fiscal year” means the period beginning on April 1 in
one year and ending on March 31 in the following year. « Loi » La Loi canadienne sur la santé. (Act)
(exercice) « 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 mi-
Minister may require the government of a province to nistre peut exiger que le gouvernement d’une province
provide the Minister with information of the following lui fournisse les renseignements suivants sur les mon-
types with respect to extra-billing in the province in a tants de la surfacturation pratiquée dans la province au
fiscal year: cours d’un 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 regard- plication de la façon dont cette estimation a été obte-
ing the method of determination of the estimate; and nue;
(b) a financial statement showing the aggregate b) un état financier indiquant le montant total de la
amount actually charged through extra-billing, includ- surfacturation effectivement imposée, accompagné
ing an explanation regarding the method of determina- d’une explication de la façon dont cet état a été établi.
tion of the aggregate amount.
CANADA HEALTH ACT — ANNUAL REPORT 2014–2015 1 161

SOR/86-259 — November 30, 2010
4. For the purposes of paragraph 13(a) of the Act, the 4. Pour l’application de l’alinéa 13a) de la Loi, le mi-
Minister may require the government of a province to nistre peut exiger que le gouvernement d’une province
provide the Minister with information of the following lui fournisse les renseignements suivants sur les mon-
types with respect to user charges in the province in a tants des frais modérateurs imposés dans la province au
fiscal year: cours 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 effecti-
amount actually charged in respect of user charges to vement imposés dans la province, accompagné d’une
which section 19 of the Act applies, including an ex- explication de la façon dont le bilan a été établi.
planation regarding the method of determination of
the aggregate amount.
TIMES AND MANNER OF FILING INFORMATION COMMUNICATION DE RENSEIGNEMENTS

5. (1) The government of a province shall provide 5. (1) Le gouvernement d’une province doit commu-
the Minister with such information, of the types pre- niquer au ministre les renseignements visés aux articles
scribed by sections 3 and 4, as the Minister may reason- 3 et 4, dont le ministre peut normalement avoir besoin,
ably require, at the following times: selon 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 avant le 1er avril de l’exercice visé par ces estimations;
to 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
paragraphs 3(b) and 4(b), before the sixteenth day of qui 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 discre- (2) Le gouvernement d’une province peut, à sa dis-
tion, provide the Minister with adjustments to the esti- crétion, fournir au ministre des ajustements aux estima-
mates referred to in paragraphs 3(a) and 4(a) before tions prévues aux alinéas 3a) et 4a), avant le 16 février
February 16 of the fiscal year to which they relate. de l’année financière visée par ces estimations.
(3) The information referred to in subsections (1) and (3) Les renseignements visés aux paragraphes (1) et
(2) shall be transmitted to the Minister by the most prac- (2) doivent être expédiés au ministre par le moyen de
tical means of communication. communication le plus pratique.

ANNEX B
POLICY INTERPRETATION LETTERS
There are two key policy statements that clarify the federal
position on the Canada Health Act. These statements
FEDERAL POLICY ON
have been made in the form of ministerial letters from PRIVATE CLINICS
former federal Health Ministers to their provincial and
territorial counterparts. 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
EPP LETTER of private clinics providing medically necessary services
funded partially by the public system and partially by patients
In June 1985, approximately one year following the passage and its impact on Canada’s universal, publicly funded health
of the Canada Health Act in Parliament, then-federal Health care system.
Minister Jake Epp wrote to his provincial and territorial
counterparts to set out and confirm the federal position on the At the September 1994 Federal/Provincial/Territorial Health
interpretation and implementation of the Canada Health Act. Ministers Meeting in Halifax, all Ministers of Health present,
with the exception of Alberta’s Health Minister, agreed to
Minister Epp’s letter followed several months of consultation “take whatever steps are required to regulate the development
with his provincial and territorial counterparts. The letter of private clinics in Canada.”
sets forth statements of federal policy intent which clarify the
criteria, conditions and regulatory provisions of the Canada Diane Marleau, the federal Minister of Health at the time,
Health Act. These clarifications have been used by the federal wrote to all provincial and territorial Ministers of Health on
government in the assessment and interpretation of compliance January 6, 1995 to announce the new Federal Policy on Private
with the Act. The Epp letter remains an important reference for Clinics. The Minister’s letter provided the federal interpretation
interpretation of the Act. of the Canada Health Act as it relates to the issue of facility
fees charged directly to patients receiving medically necessary
services at private clinics. The letter stated that the definition
of “hospital” contained in the Canada Health Act, includes any
facility that provides acute, rehabilitative or chronic care. Thus,
when a provincial or territorial health insurance plan pays the
physician fee for a medically necessary service delivered at a
private clinic, it must also pay the facility fee or face a deduction
from federal transfer payments.

ANNEX B: POLICY INTERPRETATION LETTERS
[Following is the text of the letter sent on June 18, 1985 to all provincial and territorial Ministers of Health by the Honourable Jake Epp,
federal Minister of Health and Welfare. (Note: Minister Epp sent the French equivalent of this letter to Quebec on July 15, 1985.) ]
June 18, 1985
OTTAWA, K1A 0K9
Dear Minister:
Having consulted with all provincial and territorial Ministers of Health over the past several months, both individually and
at the meeting in Winnipeg on May 16 and 17, I would like to confirm for you my intentions regarding the interpretation and
implementation of the Canada Health Act. I would particularly appreciate if you could provide me with a written indication of your
views on the attached proposals for regulations in order that I may act to have these officially put in place as soon as conveniently
possible. Also, I will write to you further with regard to the material I will need to prepare the required annual report to Parliament.
As indicated at our meeting in Winnipeg, I intend to honour and respect provincial jurisdiction and authority in matters pertaining
to health and the provision of health care services. I am persuaded, by conviction and experience, that more can be achieved through
harmony and collaboration than through discord and confrontation.
With regard to the Canada Health Act, I can only conclude from our discussions that we together share a public trust and are mutually
and equally committed to the maintenance and improvement of a universal, comprehensive, accessible and portable health insurance
system, operated under public auspices for the benefit of all residents of Canada.
Our discussions have reinforced my belief that you require sufficient flexibility and administrative versatility to operate and administer
your health care insurance plans. You know far better than I ever can, the needs and priorities of your residents, in light of geographic
and economic considerations. Moreover, it is essential that provinces have the freedom to exercise their primary responsibility for the
provision of personal health care services.
At the same time, I have come away from our discussions sensing a desire to sustain a positive federal involvement and role—both
financial and otherwise—to support and assist provinces in their efforts dedicated to the fundamental objectives of the health care
system: protecting, promoting and restoring the physical and mental well-being of Canadians. As a group, provincial/territorial
Health Ministers accept a co-operative partnership with the federal government based primarily on the contributions it authorizes
for purposes of providing insured and extended health care services.
I might also say that the Canada Health Act does not respond to challenges facing the health care system. I look forward to working
collaboratively with you as we address challenges such as rapidly advancing medical technology and an aging population and strive
to develop health promotion strategies and health care delivery alternatives.
Returning to the immediate challenge of implementing the Canada Health Act, I want to set forth some reasonably comprehensive
statements of federal policy intent, beginning with each of the criteria contained in the Act.
Public Administration
This criterion is generally accepted. The intent is that the provincial health care insurance plans be administered by a public
authority, accountable to the provincial government for decision-making on benefit levels and services, and whose records and
accounts are publicly audited.
Comprehensiveness
The intent of the Canada Health Act is neither to expand nor contract the range of insured services covered under previous federal
legislation. The range of insured services encompasses medically necessary hospital care, physician services and surgical-dental
services which require a hospital for their proper performance. Hospital plans are expected to cover in-patient and out-patient
hospital services associated with the provision of acute, rehabilitative and chronic care. As regards physician services, the range of

insured services generally encompasses medically required services rendered by licensed medical practitioners as well as surgical-
dental procedures that require a hospital for proper performance. Services rendered by other health care practitioners, except those
required to provide necessary hospital services, are not subject to the Act’s criteria.
Within these broad parameters, provinces, along with medical professionals, have the prerogative and responsibility for interpreting
what physician services are medically necessary. As well, provinces determine which hospitals and hospital services are required to
provide acute, rehabilitative or chronic care.
Universality
The intent of the Canada Health Act is to ensure that all bonafide residents of all provinces be entitled to coverage and to the benefits
under one of the twelve provincial/territorial health care insurance plans. However, eligible residents do have the option not to
participate under a provincial plan should they elect to do so.
The Agreement on Eligibility and Portability provides some helpful guidelines with respect to the determination of residency status
and arrangements for obtaining and maintaining coverage. Its provisions are compatible with the Canada Health Act.
I want to say a few words about premiums. Unquestionably, provinces have the right to levy taxes and the Canada Health Act does not
infringe upon that right. A premium scheme per se is not precluded by the Act, provided that the provincial health care insurance
plan is operated and administered in a manner that does not deny coverage or preclude access to necessary hospital and physician
services to bonafide residents of a province. Administrative arrangements should be such that residents are not precluded from or
do not forego coverage by reason of an inability to pay premiums.
I am acutely aware of problems faced by some provinces in regard to tourists and visitors who may require health services while
travelling in Canada. I will be undertaking a review of the current practices and procedures with my Cabinet colleagues, the
Minister of External Affairs, and the Minister of Employment and Immigration, to ensure all reasonable means are taken to inform
prospective visitors to Canada of the need to protect themselves with adequate health insurance coverage before entering the country.
In summary, I believe all of us as Ministers of Health are committed to the objective of ensuring that all duly qualified residents
of a province obtain and retain entitlement to insured health services on uniform terms and conditions.
Portability
The intent of the portability provisions of the Canada Health Act is to provide insured persons continuing protection under their
provincial health care insurance plan when they are temporarily absent from their province of residence or when moving from
province to province. While temporarily in another province of Canada, bonafide residents should not be subject to out-of-pocket
costs or charges for necessary hospital and physician services. Providers should be assured of reasonable levels of payment in
respect of the cost of those services.
Insofar as insured services received while outside of Canada are concerned, the intent is to assure reasonable indemnification in
respect of the cost of necessary emergency hospital or physician services or for referred services not available in a province or in
neighbouring provinces. Generally speaking, payment formulae tied to what would have been paid for similar services in a province
would be acceptable for purposes of the Canada Health Act.
In my discussions with provincial/territorial Ministers, I detected a desire to achieve these portability objectives and to minimize the
difficulties that Canadians may encounter when moving or travelling about in Canada. In order that Canadians may maintain their
health insurance coverage and obtain benefits or services without undue impediment, I believe that all provincial/territorial Health
Ministers are interested in seeing these services provided more efficiently and economically.
Significant progress has been made over the past few years by way of reciprocal arrangements which contribute to the achievement
of the in-Canada portability objectives of the Canada Health Act. These arrangements do not interfere with the rights and prerogatives
of provinces to determine and provide the coverage for services rendered in another province. Likewise, they do not deter provinces
from exercising reasonable controls through prior approval mechanisms for elective procedures. I recognize that work remains to be
done respecting interprovincial payment arrangements to achieve this objective, especially as it pertains to physician services.
I appreciate that all difficulties cannot be resolved overnight and that provincial plans will require sufficient time to meet the objective
of ensuring no direct charges to patients for necessary hospital and physician services provided in other provinces.

For necessary services provided out-of-Canada, I am confident that we can establish acceptable standards of indemnification
for essential physician and hospital services. The legislation does not define a particular formula and I would be pleased to have
your views.
In order that our efforts can progress in a coordinated manner, I would propose that the Federal-Provincial Advisory Committee
on Institutional and Medical Services be charged with examining various options and recommending arrangements to achieve the
objectives within one year.
Reasonable Accessibility
The Act is fairly clear with respect to certain aspects of accessibility. The Act seeks to discourage all point-of-service charges for
insured services provided to insured persons and to prevent adverse discrimination against any population group with respect to
charges for, or necessary use of, insured services. At the same time, the Act accents a partnership between the providers of insured
services and provincial plans, requiring that provincial plans have in place reasonable systems of payment or compensation for their
medical practitioners in order to ensure reasonable access to users. I want to emphasize my intention to respect provincial prerogatives
regarding the organization, licensing, supply, distribution of health manpower, as well as the resource allocation and priorities for
health services. I want to assure you that the reasonable access provision will not be used to intervene or interfere directly in matters
such as the physical and geographic availability of services or provincial governance of the institutions and professions that provide
insured services. Inevitably, major issues or concerns regarding access to health care services will come to my attention. I want to
assure you that my Ministry will work through and with provincial/territorial Ministers in addressing such matters.
My aim in communicating my intentions with respect to the criteria in the Canada Health Act is to allow us to work together in
developing our national health insurance scheme. Through continuing dialogue, open and willing exchange of information and
mutually understood rules of the road, I believe that we can implement the Canada Health Act without acrimony and conflict. It is
my preference that provincial/territorial Ministers themselves be given an opportunity to interpret and apply the criteria of the
Canada Health Act to their respective health care insurance plans. At the same time, I believe that all provincial/territorial Health
Ministers understand and respect my accountability to the Parliament of Canada, including an annual report on the operation of
provincial health care insurance plans with regard to these fundamental criteria.
Conditions
This leads me to the conditions related to the recognition of federal contributions and to the provision of information, both of which
may be specified in regulations. In these matters, I will be guided by the following principles:
1. to make as few regulations as possible and only if absolutely necessary;

2. to rely on the goodwill of Ministers to afford appropriate recognition of Canada’s role and contribution and to provide necessary
information voluntarily for purposes of administering the Act and reporting to Parliament;
3. to employ consultation processes and mutually beneficial information exchanges as the preferred ways and means of implementing
and administering the Canada Health Act;
4. to use existing means of exchanging information of mutual benefit to all our governments.
Regarding recognition by provincial/territorial governments of federal health contributions, I am satisfied that we can easily agree on
appropriate recognition, in the normal course of events. The best form of recognition in my view is the demonstration to the public
that as Ministers of Health we are working together in the interests of the taxpayer and patient.
In regard to information, I remain committed to maintaining and improving national data systems on a collaborative and
co-operative basis. These systems serve many purposes and provide governments, as well as other agencies, organizations, and the
general public, with essential data about our health care system and the health status of our population. I foresee a continuing,
co-operative partnership committed to maintaining and improving health information systems in such areas as morbidity, mortality,
health status, health services operations, utilization, health care costs and financing.

I firmly believe that the federal government need not regulate these matters. Accordingly, I do not intend to use the regulatory
authority respecting information requirements under the Canada Health Act to expand, modify or change these broad-based data
systems and exchanges. In order to keep information flows related to the Canada Health Act to an economical minimum, I see only
two specific and essential information transfer mechanisms:
1. estimates and statements on extra-billing and user charges;

2. an annual provincial statement (perhaps in the form of a letter to me) to be submitted approximately six months after the
completion of each fiscal year, describing the respective provincial health care insurance plan’s operations as they relate to the
criteria and conditions of the Canada Health Act.
Concerning Item 1 above, I propose to put in place on-going regulations that are identical in content to those that have been
accepted for 1985–86. Draft regulations are attached as Annex I. To assist with the preparation of the “annual provincial statement”
referred to in Item 2 above, I have developed the general guidelines attached as Annex II. Beyond these specific exchanges, I am
confident that voluntary, mutually beneficial exchange of such subjects as Acts, regulations and program descriptions will continue.
One matter brought up in the course of our earlier meetings, is the question of whether estimates or deductions of user charges and
extra-billing should be based on “amounts charged” or “amounts collected”. The Act clearly states that deductions are to be based
on amounts charged. However, with respect to user fees, certain provincial plans appear to pay these charges indirectly on behalf of
certain individuals. Where a provincial plan demonstrates that it reimburses providers for amounts charged but not collected, say in
respect of social assistance recipients or unpaid accounts, consideration will be given to adjusting estimates/deductions accordingly.
I want to emphasize that where a provincial plan does authorize user charges, the entire scheme must be consistent with the intent
of the reasonable accessibility criterion as set forth [in this letter].
Regulations
Aside from the recognition and information regulations referred to above, the Act provides for regulations concerning hospital services
exclusions and regulations defining extended health care services.
As you know, the Act provides that there must be consultation and agreement of each and every province with respect to such
regulations. My consultations with you have brought to light few concerns with the attached draft set of Exclusions from Hospital
Services Regulations.
Likewise, I did not sense concerns with proposals for regulations defining Extended Health Care Services. These help provide greater
clarity for provinces to interpret and administer current plans and programs. They do not alter significantly or substantially those that
have been in force for eight years under Part VI of the Federal Post-Secondary Education and Health Contributions Act (1977). It may
well be, however, as we begin to examine the future challenges to health care that we should re-examine these definitions.
This letter strives to set out flexible, reasonable and clear ground rules to facilitate provincial, as much as federal, administration of
the Canada Health Act. It encompasses many complex matters including criteria interpretations, federal policy concerning conditions
and proposed regulations. I realize, of course, that a letter of this sort cannot cover every single matter of concern to every provincial
Minister of Health. Continuing dialogue and communication are essential.
In conclusion, may I express my appreciation for your assistance in bringing about what I believe is a generally accepted concurrence
of views in respect of interpretation and implementation. As I mentioned at the outset of this letter, I would appreciate an early
written indication of your views on the proposals for regulations appended to this letter. It is my intention to write to you in the near
future with regard to the voluntary information exchanges which we have discussed in relation to administering the Act and reporting
to Parliament.
Yours truly,
Jake Epp
Attachments

[Following is the text of the letter sent on January 6, 1995 to all provincial and territorial Ministers of Health by the federal Minister
of Health, the Honourable Diane Marleau.]
January 6, 1995
Dear Minister:
RE: Canada Health Act
The Canada Health Act has been in force now for just over a decade. The principles set out in the Act (public administration, compre-
hensiveness, universality, portability and accessibility) continue to enjoy the support of all provincial and territorial governments. This
support is shared by the vast majority of Canadians. At a time when there is concern about the potential erosion of the publicly funded
and publicly administered health care system, it is vital to safeguard these principles.
As was evident and a concern to many of us at the recent Halifax meeting, a trend toward divergent interpretations of the Act is
developing. While I will deal with other issues at the end of this letter, my primary concern is with private clinics and facility fees.
The issue of private clinics is not new to us as Ministers of Health; it formed an important part of our discussions in Halifax last
year. For reasons I will set out below, I am convinced that the growth of a second tier of health care facilities providing medically
necessary services that operate, totally or in large part, outside the publicly funded and publicly administered system, presents a
serious threat to Canada’s health care system.
Specifically, and most immediately, I believe the facility fees charged by private clinics for medically necessary services are a major
problem which must be dealt with firmly. It is my position that such fees constitute user charges and, as such, contravene the principle
of accessibility set out in the Canada Health Act.
While there is no definition of facility fees in federal or most provincial legislation, the term, generally speaking, refers to amounts
charged for non-physician (or “hospital”) services provided at clinics and not reimbursed by the province. Where these fees are
charged for medically necessary services in clinics which receive funding for these services under a provincial health insurance plan,
they constitute a financial barrier to access. As a result, they violate the user charge provision of the Act (section 19).
Facility fees are objectionable because they impede access to medically necessary services. Moreover, when clinics which receive
public funds for medically necessary services also charge facility fees, people who can afford the fees are being directly subsidized
by all other Canadians. This subsidization of two-tier health care is unacceptable.
The formal basis for my position on facility fees is twofold. The first is a matter of policy. In the context of contemporary health care
delivery, an interpretation which permits facility fees for medically necessary services so long as the provincial health insurance plan
covers physician fees runs counter to the spirit and intent of the Act. While the appropriate pro-vision of many physician services at
one time required an overnight stay in a hospital, advances in medical technology and the trend toward providing medical services
in more accessible settings has made it possible to offer a wide range of medical procedures on an out-patient basis or outside of
full-service hospitals. The accessibility criterion in the Act, of which the user charge provision is just a specific example, was clearly
intended to ensure that Canadian residents receive all medically necessary care without financial or other barriers and regardless of
venue. It must continue to mean that as the nature of medical practice evolves.
Second, as a matter of legal interpretation, the definition of “hospital” set out in the Act includes any facility which pro-vides acute,
rehabilitative or chronic care. This definition covers those health care facilities known as “clinics”. As a matter of both policy and
legal interpretation, therefore, where a provincial plan pays the physician fee for a medically necessary service delivered at a clinic,
it must also pay for the related hospital services provided or face deductions for user charges.
I recognize that this interpretation will necessitate some changes in provinces where clinics currently charge facility fees for
medically necessary services. As I do not wish to cause undue hardship to those provinces, I will commence enforcement of this
interpretation as of October 15, 1995. This will allow the provinces the time to put into place the necessary legislative or regulatory
framework. As of October 15, 1995, I will proceed to deduct from transfer payments any amounts charged for facility fees in respect
of medically necessary services, as mandated by section 20 of the Canada Health Act. I believe this provides a reasonable transition
period, given that all provinces have been aware of my concerns with respect to private clinics for some time, and given the

promising headway already made by the Federal/Provincial/Territorial Advisory Committee on Health Services, which has been
working for some time now on the issue of private clinics.
I want to make it clear that my intent is not to preclude the use of clinics to provide medically necessary services. I realize that
in many situations they are a cost-effective way to deliver services, often in a technologically advanced manner. However, it is my
intention to ensure that medically necessary services are provided on uniform terms and conditions, wherever they are offered.
The principles of the Canada Health Act are supple enough to accommodate the evolution of medical science and of health care
delivery. This evolution must not lead, however, to a two-tier system of health care.
I indicated earlier in this letter that, while user charges for medically necessary services are my most immediate concern, I am
also concerned about the more general issues raised by the proliferation of private clinics. In particular, I am concerned about
their potential to restrict access by Canadian residents to medically necessary services by eroding our publicly funded system.
These concerns were reflected in the policy statement which resulted from the Halifax meeting. Ministers of Health present,
with the exception of the Alberta Minister, agreed to:
take whatever steps are required to regulate the development of private clinics in Canada, and to maintain a high quality,
publicly funded medicare system.
Private clinics raise several concerns for the federal government, concerns which provinces share. These relate to:
■■ weakened public support for the tax funded and publicly administered system;
■■ the diminished ability of governments to control costs once they have shifted from the public to the private sector;
■■ the possibility, supported by the experience of other jurisdictions, that private facilities will concentrate on easy procedures,
leaving public facilities to handle more complicated, costly cases; and
■■ the ability of private facilities to offer financial incentives to health care providers that could draw them away from the public
system—resources may also be devoted to features which attract consumers, without in any way contributing to the quality of care.
The only way to deal effectively with these concerns is to regulate the operation of private clinics.
I now call on Ministers in provinces which have not already done so to introduce regulatory frameworks to govern the operation of pri-
vate 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

ANNEX C
DISPUTE AVOIDANCE AND

RESOLUTION PROCESS UNDER
THE CANADA HEALTH ACT
In April 2002, the Honourable A. Anne McLellan outlined in If these are unsuccessful, either Minister of Health involved
a letter to her provincial and territorial counterparts a Canada may refer the issues to a third party panel to undertake fact-
Health Act Dispute Avoidance and Resolution process, which finding and provide advice and recommendations.
was agreed to by provinces and territories, except Quebec. The
process meets federal and provincial/territorial interests of The federal Minister of Health has the final authority to interpret
avoiding disputes related to the interpretation of the principles and enforce the Canada Health Act. In deciding whether to invoke
of the Canada Health Act, and when this is not possible, the non-compliance provisions of the Act, the Minister will take
resolving disputes in a fair, transparent and timely manner. the panel’s report into consideration.
The process includes the dispute avoidance activities of In September 2004, the agreement reached between the
government-to-government information exchange; discussions provinces and territories in 2002 was formalized by First
and clarification of issues, as they arise; active participation of Ministers, thereby reaffirming their commitment to use the
governments in ad hoc federal/provincial/territorial committees Canada Health Act Dispute Avoidance and Resolution process
on Canada Health Act issues; and Canada Health Act advance to deal with Canada Health Act interpretation issues.
assessments, upon request.
On the following pages you will find the full text of Minister
Where dispute avoidance activities prove unsuccessful, McLellan’s Letter to the Honourable Gary Mar, as well as a
dispute resolution activities may be initiated, beginning with fact sheet on the Canada Health Act Dispute Avoidance and
government-to-government fact-finding and negotiations. Resolution Process.

ANNEX C: DISPUTE AVOIDANCE AND RESOLUTION PROCESS UNDER THE CANADA HEALTH ACT
Minister of Health Ministre de la Santé
Ottawa, Canada K1A 0K9
April 2, 2002
The Honourable Gary Mar, M.L.A.

Minister of Health and Wellness
Province of Alberta
Room 323, Legislature Building
Edmonton, Alberta
T5K 2B6
Dear Mr. Mar:
I am writing in fulfilment of my commitment to move forward on dispute avoidance and resolution as it applies to the interpretation
of the principles of the Canada Health Act.
I understand the importance provincial and territorial governments attach to having a third party provide advice and recommendations
when differences occur regarding the interpretation of the Canada Health Act. This feature has been incorporated in the approach to the
Canada Health Act Dispute Avoidance and Resolution process set out below. I believe this approach will enable us to avoid and resolve
issues related to the interpretation of the principles of the Canada Health Act in a fair, transparent and timely manner.
Dispute Avoidance
The best way to resolve a dispute is to prevent it from occurring in the first place. The federal government has rarely resorted to
penalties and only when all other efforts to resolve the issue have proven unsuccessful. Dispute avoidance has worked for us in the
past and it can serve our shared interests in the future. Therefore, it is important that governments continue to participate actively in
ad hoc federal/provincial/territorial committees on Canada Health Act issues and undertake government-to-government information
exchange, discussions and clarification on issues as they arise.
Moreover, Health Canada commits to provide advance assessments to any province or territory upon request.
Dispute Resolution
Where the dispute avoidance activities between the federal government and a provincial or territorial government prove unsuccessful,
either Minister of Health involved may initiate dispute resolution by writing to his or her counterpart. Such a letter would describe the
issue in dispute. If initiated, dispute resolution will precede any action taken under the non-compliance provisions of the Act.

As a first step, governments involved in the dispute will, within 60 days of the date of the letter initiating the process, jointly:
■■ collect and share all relevant facts;

■■ prepare a fact-finding report;
■■ negotiate to resolve the issue in dispute; and
■■ prepare a report on how the issue was resolved.
If, however, there is no agreement on the facts, or if negotiations fail to resolve the issue, any Minister of Health involved in the
dispute may initiate the process to refer the issue to a third party panel by writing to his or her counterpart. Within 30 days of
the date of that letter, a panel will be struck. The panel will be composed of one provincial/territorial appointee and one federal
appointee who, together, will select a chairperson. The panel will assess the issue in dispute in accordance with the provisions
of the Canada Health Act, will undertake fact-finding and provide advice and recommendations. It will then report to the
governments involved on the issue within 60 days of appointment.
The Minister of Health for Canada has the final authority to interpret and enforce the Canada Health Act. In deciding whether to
invoke the non-compliance provisions of the Act, the Minister of Health for Canada will take the panel’s report into consideration.
Public Reporting
Governments will report publicly on Canada Health Act dispute avoidance and resolution activities, including any panel report.
I believe that the Government of Canada has followed through on its September 2000 Health Agreement commitments by providing
funding of $21.1 billion in the fiscal framework and by working collaboratively in other areas identified in the agreement. I expect that
provincial and territorial premiers and Health Ministers will honour their commitment to the health system accountability framework
agreed to by First Ministers in September 2000. The work of officials on performance indicators has been collaborative and effective
to date. Canadians will expect us to report on the full range of indicators by the agreed deadline of September 2002. While I am
aware that some jurisdictions may not be able to fully report on all indicators in this timeframe, public accountability is an essential
component of our effort to renew Canada’s health care system. As such, it is very important that all jurisdictions work to report on the
full range of indicators in subsequent reports.
In addition, I hope that all provincial and territorial governments will participate in and complete the joint review process agreed to
by all Premiers who signed the Social Union Framework Agreement.
The Canada Health Act Dispute Avoidance and Resolution process outlined in this letter is simple and straightforward. Should
adjustments be necessary in the future, I commit to review the process with you and other Provincial/Territorial Ministers of
Health. By using this approach, we will demonstrate to Canadians that we are committed to strengthening and preserving medicare
by preventing and resolving Canada Health Act disputes in a fair and timely manner.
Yours sincerely,
A. Anne McLellan

FACT SHEET: CANADA HEALTH If however, there is no agreement on the facts, or if negotiations
fail to resolve the issue, any Minister of Health involved in
ACT DISPUTE AVOIDANCE AND the dispute may initiate the process to refer the issue to a third
RESOLUTION PROCESS 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
Scope appointee and one federal appointee, who together will select
The provisions described apply to the interpretation of the a chairperson.
principles of the Canada Health Act. ■■ 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.
Dispute Avoidance ■■ The panel will then report to the governments involved on
To avoid and prevent disputes, governments will continue to: the issue within 60 days of appointment.
■■ participate actively in ad hoc federal/provincial/territorial The Minister of Health for Canada has the final authority
committees on Canada Health Act issues; and to interpret and enforce the Canada Health Act. In deciding
whether to invoke the non-compliance provisions of the Act,
■■ undertake government-to-government information the Minister of Health for Canada will take the panel’s report
exchange, discussions and clarification on issues as they arise. into consideration.
Health Canada commits to provide advance assessments to any
province or territory upon request.
Public Reporting
Governments will report publicly on Canada Health Act dispute
Dispute Resolution avoidance and resolution activities, including any panel report.
Where the dispute avoidance activities between the federal
government and a provincial or territorial government prove
unsuccessful, either Minister of Health involved may initiate
Review
dispute resolution by writing to his or her counterpart. Such Should adjustments be necessary in the future, the Minister
a letter would describe the issue in dispute. If initiated, of Health for Canada commits to review the process with
dispute resolution will precede any action taken under Provincial and Territorial Ministers of Health.
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.

CONTACT INFORMATION FOR PROVINCIAL AND TERRITORIAL DEPARTMENTS OF HEALTH
NEWFOUNDLAND AND LABRADOR MANITOBA

Department of Health and Community Services Manitoba Health
Confederation Building 300 Carlton Street
P.O. Box 8700 Winnipeg, MB R3B 3M9
St.John’s, NL A1B 4J6 1-800-392-1207
(709) 729-5021 www.manitoba.ca/health
www.gov.nl.ca/health
SASKATCHEWAN
PRINCE EDWARD ISLAND Saskatchewan Health
Department of Health and Wellness 3475 Albert Street
P.O. Box 2000 Regina, SK S4S 6X6
Charlottetown, PE C1A 7N8 1-800-667-7766
(902) 368-6130 Email info@health.gov.sk.ca
www.gov.pe.ca/health www.saskatchewan.ca
NOVA SCOTIA ALBERTA

Department of Health and Wellness Alberta Health
1894 Barrington Street P.O. Box 1360, Station Main
P.O. Box 488 Edmonton, AB T5J 2N3
Halifax, NS B3J 2A8 (780) 427-7164
(902) 424-5818 www.health.alberta.ca
1-800-387-6665 (toll-free in Nova Scotia)
1-800-670-8888 (TTY/TDD) BRITISH COLUMBIA
www.novascotia.ca/DHW
Ministry of Health
1515 Blanshard Street
NEW BRUNSWICK Victoria, BC V8W 3C8
Department of Health (250) 952-1742
P.O. Box 5100 1-800-465-4911 (toll-free in B.C.)
Fredericton, NB E3B 5G8 www.gov.bc.ca/health
(506) 457-4800
www.gnb.ca/health YUKON
Department of Health and Social Services
QUEBEC Insured Health Services Branch H-2
Ministry of Health and Social Services P.O. Box 2703
1075 Sainte-Foy Road Whitehorse, YT Y1A 2C6
Québec, QC G1S 2M1 1-867-667-5202
(418) 266-7005 www.hss.gov.yk.ca
www.msss.gouv.qc.ca
NORTHWEST TERRITORIES
ONTARIO Department of Health and Social Services
Ministry of Health and Long-Term Care P.O. Box 1320
10th Floor, Hepburn Block Yellowknife, NWT X1A 2L9
80 Grosvenor Street 1-800-661-0830 or 1-867-767-9053
Toronto, ON M7A 1R3 www.hlthss.gov.nt.ca
1-800-268-1153
www.health.gov.on.ca NUNAVUT
Department of Health
P.O. Box 1000, Station 1000
Iqaluit, NU X0A 0H0
1-867-975-5700
www.gov.nu.ca/health
CANADA HEALTH ACT
CANADA HEALTH ACT

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Universality Universality
ANNUAL REPORT 2014–2015

Comprehensiveness Comprehensiveness
Portability Portability
ANNUAL 2014
REPORT 2015

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CANADA HEALTH ACT

CANADA HEALTH ACT

ANNUAL REPORT 2014–2015

Published by authority of the Minister of Health.

Canada Health Act – Annual Report 2014–2015

Également disponible en français sous le titre:

For further information or to obtain additional copies, please contact:

Telephone: (613) 957-2991

Newfoundland and Labrador Department of Health and Community Services

Prince Edward Island Department of Health and Wellness

Nova Scotia Department of Health and Wellness

New Brunswick Department of Health

Quebec Ministry of Health and Social Services

Ontario Ministry of Health and Long-Term Care

Manitoba Health, Healthy Living and Seniors

British Columbia Ministry of Health

Yukon Health and Social Services

Northwest Territories Department of Health and Social Services

Nunavut Department of Health

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 i

Chapter 1 — Canada Health Act Overview_________________________________________________________________________3

Chapter 2 — Administration and Compliance______________________________________________________________________11

Chapter 3 — Provincial and Territorial Health Care Insurance Plans in 2013–2014________________________________________19

Newfoundland and Labrador________________________________________________________________________21

Prince Edward Island______________________________________________________________________________31

Northwest Territories____________________________________________________________________________ 125

Annex B — Policy Interpretation Letters________________________________________________________________________163

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 iii

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 1

CANADA HEALTH ACT OVERVIEW

Extended health care services, as defined in the Act, are

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 3

REQUIREMENTS OF THE 4. Portability (section 11)

4 CANADA HEALTH ACT ANNUAL REPORT 2014–2015

The Conditions User Charges (section 19)

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 5

Discretionary Penalty Provisions Excluded Persons

There is a Frequently Asked Questions link on Health Canada’s

6 CANADA HEALTH ACT ANNUAL REPORT 2014–2015

At the September 1994 federal/provincial/territorial meeting

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 7

8 CANADA HEALTH ACT ANNUAL REPORT 2014–2015

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 9

ADMINISTRATION ■■ working with Health Canada Legal Services and Justice

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 11

COMPLIANCE Under the CHA, the definition of “hospital services” specifies

12 CANADA HEALTH ACT ANNUAL REPORT 2014–2015

In March 2015, Health Canada wrote to the Quebec Ministry HISTORY OF DEDUCTIONS

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 13

14 CANADA HEALTH ACT ANNUAL REPORT 2014–2015

CANADA HEALTH ACT ANNUAL REPORT 2014–2015 15

DEDUCTIONS AND REFUNDS TO CHST/CHT CASH CONTRIBUTIONS IN ACCORDANCE

NL 0 46,000 96,000 128,000 53,000 (42,570) 0 0 0 0 1,100

MB 0 269,000 588,000 586,000 612,000 0 0 300,201 0 0 0

BC 1,982,000 43,000 0 0 0 0 0 0 4,610 126,775 72,464

Understanding This Chart

16 CANADA HEALTH ACT ANNUAL REPORT 2014–2015

DEDUCTIONS AND REFUNDS TO CHST/CHT CASH CONTRIBUTIONS IN ACCORDANCE

0 0 0 0 0 3,577 58,679 50,758 (10,765) 0 383,779